Rapid action insulin formulations and pharmaceutical delivery systems

ABSTRACT

The present invention provides rapid-acting insulin and insulin analogue formulations. The invention further provides delivery devices, particularly infusion sets, which allow for the rapid absorption of insulin and insulin analogues, as well as other active agents. Methods of using the insulin and insulin analogue formulations as well as the insulin delivery devices for treating subjects with diabetes mellitus are also provided.

RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional PatentApplication No. 61/926,944, filed Jan. 13, 3014, and U.S. ProvisionalPatent Application No. 61/926,946, filed Jan. 13, 2014, each of whichare hereby incorporated by reference in their entireties.

STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

This invention was made partially with government support under SBIRgrants awarded by the National Institutes of Health under grant numbers1R43DK092041, 1R43DK088506, 1R43DK094668, 5R44DK088506, 5R43DK094668,1R43DK100186, 1R43DK100190, 2R44DK092041, 1R43DK103445, 1R41DK081292,and 1R43DK089831. The U.S. government has certain rights to theinvention.

TECHNICAL FIELD

The present invention relates in part to pharmaceutical formulations anddelivery systems.

BACKGROUND

Diabetes mellitis denotes a spectrum of metabolic diseases characterizedby abnormally high blood glucose levels. There are two major types ofdiabetes. Type 1 diabetes results from the body's failure to produceinsulin. For these patients, administration of insulin is the onlyavailable therapy. Type 2 diabetes typically begins with insulinresistance, a condition in which the body's cells fail to respond toinsulin. As the disease progresses, a relative or absolute lack ofinsulin production also develops. Type 2 diabetes is often associatedwith excessive body weight and lack of exercise. The treatment for Type2 diabetes typically starts with exercise and diet management as well asmedications without insulin. As the disease deteriorates, many patientswith Type 2 diabetes eventually require insulin therapy to support theirmetabolism.

In healthy individuals, insulin secretion is closely tied to bloodglucose level. Increased glucose level, for example, after meals, iscompensated by a rapid increase in insulin release within minutes ofglucose entry into the blood. In the fasting state, insulin level fallsto a basal level, which is sufficient to guarantee a continuous supplyof glucose to insulin-sensitive organs and tissues. The objective ofinsulin therapy is to replicate this natural time-action profile ofinsulin in diabetic patients, such that blood glucose level can staywithin the normal range characteristic of healthy individuals. However,current insulin products and delivery systems do not sufficiently meetthis objective due to limitations in the absorption of the insulin orinsulin analogue.

For example, when insulin is solubilized in a buffer without zinc andstored at room temperature (25-30° C.), the insulin will begin to formamyloid fibrils within 7-14 days. To avoid this problem, currentlyavailable insulin products are typically formulated with zinc, whichforms a complex with insulin called a zinc-insulin hexamer. Zinc-insulinhexamers can be stable in solution at room temperature for greater than30 days, which is long enough to meet regulatory requirements forinsulin formulation stability. However, zinc-insulin hexamers are toolarge to be readily absorbed by capillaries, and so the hexamers mustdisassemble after injection before the insulin can be absorbed. Thisprevents these formulations from being absorbed quickly enough.

Accordingly, there is an unmet need for insulin compositions,formulations, and delivery systems that better replicate the naturaltime-action profile of insulin.

SUMMARY OF THE INVENTION

The present invention relates in part to rapid-acting insulincompositions, formulations and delivery systems that better replicatethe natural activity profile of insulin (i.e., on pancreatic secretionin human subjects without diabetes mellitus). The invention especiallyrelates to prandial insulin administered before or during meals todiabetic patients. In various aspects, the invention provides insulincompositions, formulations, delivery systems, and methods of treatmentthat provide for the rapid absorption of insulin and insulin analogues.When used in combination with a basal insulin formulation in someembodiments, or in an artificial pancreas system, the invention providesfor tighter control of glucose levels.

In other aspects, the invention provides infusion sets that enhance theabsorption of pharmaceutical formulations (including but not limited toinsulin) through energy delivery systems.

In various aspects and embodiments, the invention provides for an onsetof insulin activity of less than about 40 minutes after administration,and in some embodiments the onset of activity is within about 30minutes, or within about 20 minutes, or within about 15 minutes afteradministration. In some embodiments, the insulin reaches T_(max) at lessthan about 60 minutes after administration, and less than about 40minutes in some embodiments. In further embodiments, the inventionprovides a duration of insulin activity of about five hours or less,including about three hours or less or about two hours or less in someembodiments.

In one aspect, the invention provides a pharmaceutical compositioncomprising an effective amount of a monomeric insulin analogue and oneor more calcium ion-chelating agents and/or charge-masking agents. Invarious embodiments, the pharmaceutical composition or formulation is asubstantially zinc-free formulation, thereby avoiding insulin hexamerassembly. The pharmaceutical compositions of the present inventioncomprise a monomeric insulin analogue which may have one or moremutations that reduce or eliminate fibril formation or reduce theformation of degradation products such as covalent dimers/polymers orrelated substances, thus maintaining stability of the insulin in amonomeric or dimeric state. In some embodiments, the insulin is asingle-chain insulin analogue or an insulin analogue with natural ornon-natural amino acid mutations. Various insulin analogues that finduse with the various aspects of the invention are described in detailherein. In various embodiments, the monomeric insulin analogue isformulated at from about U10 to about U2000. In various embodiments, theinsulin analogue is formulated at U100 or greater (e.g., about U200,about U300, about U400, about U500, about U1000, about U1500, or aboutU2000) without significant fibril formation. For example, in variousembodiments, the pharmaceutical composition is stable for at least about1 month, at least about 6 months, at least about 9 months, or at leastabout 12 months at 25° C. without substantial formation of insulinfibrils.

The pharmaceutical composition of the invention includes one or morecalcium ion-chelating agents and/or charge-masking agents. In someembodiments, the agent includes one or more amino organic acids, ionicsalts (e.g., comprising cations of Na, K, Mg, etc.), polycarboxylic acidcompounds, anionic polysaccharides, organosulfur compounds, di- ortri-carboxylic acids, penicillamine, and extract or partial extract ofchlorella and/or cilantro. In various embodiments, without being limitedby theory, the agent masks charges in the subcutaneous tissue, whichallows charged surfaces on insulin and insulin analogues to avoid being“trapped” by charged elements in the tissue or interstitial fluid and tomore rapidly move toward the blood or lymphatic vessels for absorption.In some embodiments, without being limited by theory, the chelation ofcalcium ions in the subcutaneous tissue promotes disassembly of adherensjunctions and tight junctions (i.e., protein complexes at cell-celljunctions linked to the cellular cytoskeleton), and other forms of tightjunctions between cells, for example in the vessel endothelium, therebyincreasing the rate of insulin absorption. The compositions andformulations of the invention can be packaged in solution form,including sterile vials and pre-filled injection pens or cartridges, andmay be used with infusion sets employing an insulin pump.

In another aspect, the present invention provides an infusion set whichmay be used with a rapid-acting insulin formulation as well as otherpharmaceutical formulations, and one or more energy-delivery systemssuch as an ultrasound transducer, a tactor, and an electrophoresiselectrode. The energy-delivery system increases absorption of thepharmaceutical formulation by promoting the migration of the activeagent to the vasculature from a subcutaneous depot or by increasingblood circulation to the area. The ultrasound transducer may be a lowintensity ultrasound (LITUS) transducer, and the tactor may be alow-frequency piezoelectric tactor.

In various embodiments, the infusion set comprises a first body, anadhesive surface, a subcutaneous infusion catheter, and one or more ofan ultrasound transducer, a tactor, and an electrophoresis electrode. Incertain embodiments employing electrophoresis, the infusion set includesa first electrophoresis electrode proximal to the distal end of theinfusion catheter (e.g., a cathode), and a second electrophoresiselectrode on or near the skin surface (e.g., an anode), which can beattached to the adhesive surface of the infusion set. This design willpromote, for example, insulin migration (especially negatively chargedinsulin analogs) from the tip of the catheter toward the vessels at thetop of the subcutis. In some embodiments, the insulin analogue (or otheractive agent) has a net charge in the range of −2 to −6. In someembodiments, the insulin formulation exhibits increased hexamerdisassembly, or is a monomeric insulin analogue that is stable andprovided in a substantially zinc-free formulation that avoids hexamerassembly.

Other aspects of the invention will be apparent from the followingdetailed description of the invention.

DESCRIPTION OF THE FIGURES

FIG. 1 is a diagram of the anatomy of the skin.

FIG. 2 shows a histological section of skin, and the approximate volumeof an insulin injectate.

FIG. 3 shows a cause and effect tree identifying potential strategiesfor increasing the absorption of subcutaneously administered insulin.

FIG. 4 shows the rate of onset of insulin action from euglycemic clampstudies in Yorkshire swine. Onset of insulin action is measured in thisexample as time to ½ maximum potency. Studies use a monomeric insulin(Fluorolog). Studies with and without EDTA are shown.

FIG. 5 shows an UltrOZ device applied to a shaved injection site on aSinclair pig.

FIG. 6 shows the result of euglycemic clamp studies of subcutaneouslispro insulin injection in a single Sinclair pig, which demonstrates:faster onset, a longer plateau, and essentially identical potency (AUC)for injection exposed to ultrasound.

FIG. 7A shows a schematic of the top view of a prototype infusion sethead. FIG. 7B shows a schematic of the side view of a prototype infusionset head with possible locations of ultrasound Transducers (3).

FIGS. 8A-8C show schematics of electrophoresis infusion sets. FIGS. 8Aand 8B show the top and side views, respectively, of a configurationwith the anode (5) placed on the adhesive patch away from the infusionset head. FIG. 8C show a configuration with the anode placed directlyover the infusion site.

FIGS. 9A and 9B show the top and side views, respectively, of aschematic of a skin surface electrode in ring shape.

FIG. 10 shows how negatively charged insulin depot migrates rapidly tothe lower dermis under electromotive force (EMF).

FIGS. 11A and 11B demonstrate that insulin and various analogs ofinsulin migrate in gradient acrylamide gel at pH 7 @ 0.5 mA/cm for 15 m.FIG. 11A is a table of results, including a key to the wells shown inFIG. 11B. FIG. 11B is a picture of an exemplary acrylamide gel.

FIGS. 12A and 12B show a diagram of the Franz apparatus used todemonstrate insulin migration in tissue (12A) and the actualimplementation of that apparatus (12B).

FIG. 13 shows Porcine skin following treatment with bromophenol blue(0.05%, pH7.3) without (zero V) and with (10 V) EMF through the fullthickness skin layers at 37° C. for one hour. The negatively chargedbromophenol blue penetrated the tissue under the influence of the EMF.

FIG. 14 shows the localization of Cy5-insulin in pig skin after 1 hourof electrophoresis under an EMF of 10 V. Epidermis is to the left.

FIG. 15 shows two representative control samples (no voltage applied)and two test skin samples (10 volts applied) exposed to LisPro insulinon the subcutaneous surface during a one-hour treatment period. All skinsamples were from the same animal and are oriented with the epidermis onthe left and the subcutis on the right. The left column images are skinthin sections stained with H&E. The middle column depicts thebright-field (BF) images that correspond to the Alexa 594 images (rightcolumn). In tissues where no voltage was applied, the Alexa 594 label isvisible only at the subcutaneous surface (Control #1) or is undetectablein any skin layer (Control #2). By comparison, the Alexa 594 images fromtest samples 1 and 2 indicate fluorescence label through all layers ofskin, with concentration (Test #1) at the hypodermal boundary,indicating detectable insulin movement from the subcutaneous surfaceinto the deeper skin layers.

FIG. 16 shows the effect of various charge-blocking excipients on theonset of action after subcutaneous injection of monomeric insulin analogT-0339.

FIGS. 17A-C shows the effect of various charge-blocking excipients onthe onset of action (T_(max) ½ early) after subcutaneous injection ofmonomeric insulin analog T-0339 (U500), in three pig studies. +SEM errorbars displayed if n>1.

FIG. 18A-C shows AUC ½ late for the same pig studies of FIG. 17. +SEMerror bars displayed if n>1.

FIG. 19A-C shows the T_(max) ½ late for the same pig studies of FIG. 17.+SEM error bars displayed if n>1.

DETAILED DESCRIPTION

The present invention provides rapid-acting insulin, and insulinanalogue formulations. The invention further provides delivery devices,particularly infusion sets, that promote the rapid absorption of insulinand insulin analogues (or other pharmaceutical formulation), includingmonomeric insulin analogues. Methods of using the insulin and insulinanalogue formulations as well as the insulin delivery devices fortreating subjects with diabetes are also provided.

Insulin therapy has been used for more than 90 years to treat diabetes.Typically, therapy involves multiple insulin injections every day.According to the conventional regimen, patients are treated with one ortwo daily insulin injections of long-acting insulin to cover the basalinsulin requirement supplemented with injections of a fast-actinginsulin formulation (or fast-acting insulin analogue formulation) tocover the insulin requirement related to meals. However, even whenproperly and timely administered, insulin injections often do not mimicthe natural action profile of insulin. For example, availablerapid-acting insulin analogues enter into blood and the site of actiontoo slowly, and have too long an overall duration of action. Thisresults in inadequate insulin levels at the initiation of a meal and toomuch insulin present between (and particularly immediately after) meals.In turn, this lag in insulin delivery causes hyperglycemia early afterstarting a meal and hypoglycemia after meals.

Insulin is typically delivered through the subcutaneous tissue. Thesubcutaneous tissue (“subcutis” or “s.q.”) sits below the epidermis(which is about 0.05 to 1 mm thick) and the dermis (which is about 0.3-3mm thick) and consists of fat lobules separated by fibrous septae.Individual lobules may be up to 3 mm thick and are made up of primaryand secondary microlobules (FIG. 1). The entire subcutis may be between3 and 20 mm thick. Blood supply is relatively sparse (especiallycompared to the dermis), although there are typically vessel plexi atthe top (near the interface with the dermis) and bottom of the subcutis.There are lymphatic vessels in the subcutis as well.

Subcutaneous delivery can be achieved by needles (typically 3-13 mmlong) for individual injections or by infusion catheter (which aretypically 6-9 mm long), e.g., for continuous subcutaneous insulininfusion (CSII). The latter is connected to an infusion set connected toan insulin pump and is typically placed using an insertion device. Inboth cases, insulin is delivered into the tissue from the distal end ofthe lumen, which is between 2 and 11 mm from the skin surface. The lumenis typically between 0.2 and 0.4 mm in diameter. For CSII, basal insulinis delivered as frequent micro-boluses of rapid-acting insulin. However,all meal-time insulin analogue formulations are typically delivered as abolus, typically with an injection volume of between 20 and 500 whichfills an area about 2.7 to 8 mm in diameter (FIG. 2).

An infusion set typically comprises a first body with an adhesivesurface to adhere to the epidermis, an infusion catheter that isinserted through the epidermis and dermis into the subcutis (often usingan insertion device), and a supply tube in continuous fluid contact withthe catheter. Infusion sets are typically placed once a day or onceevery other day. An infusion set can be used to deliver any liquidpharmaceutical formulation into the subcutis.

Insulin boluses initially pool (form a depot) near the end of the lumen,thereby displacing and compressing the local fat lobules and stretchingthe local septae. The insulin then must diffuse through the basesubstance in the septae in order to reach capillaries and venules, whereit is eventually absorbed through the vessel lumens into the blood.Absorption into blood vessels is difficult since the vessels havepositive fluid pressure and are more likely to leak than absorb. Insulinhexamers are too big to be absorbed, and so hexameric insulinformulations must disassemble into dimers or monomers before the insulincan be absorbed.

The rapidity of insulin action largely depends on how quickly it isabsorbed from the subcutis. The active form of insulin in the bloodstream is the monomer. However, insulin formulations (or insulinanalogue formulations) containing a predominance of protein molecules inthe forms of monomers and dimers ordinarily have a strong tendency toaggregate and form inactive fibrils. Thus, typical commercial insulinformulations at 100 IU/mL (i.e., U100) are composed of hexamers with twozinc atoms that stabilize the molecular assembly and its componentmonomeric units. Insulin formulations prepared in the form of zinchexamers have a sufficient shelf life (e.g., 30 days at 30° C.), but arenot readily absorbed largely due to their size. The hexamers must firstdisassemble for absorption through blood vessels.

Attempts have been made to ameliorate this problem. For example, WO2007/121256 and WO 2010/102020 teach mixing a hexameric insulin withEDTA and citrate before administration, with the objective of chelatingthe zinc out of the hexamers and masking charges on the insulin toinhibit hexamer formation, thereby forcing pre-injection hexamerdisassembly. Although this approach may speed insulin absorption, italso destabilizes the insulin formulation or requires mixing excipientwith the hexameric insulin before each administration. Not only are suchstrategies undesirable in terms of patient convenience and compliance,but such strategies are also poor candidates for insulin pump systemsand for use in continuous or automated delivery systems.

However, even in the case of monomeric and/or dimeric insulin analogueformulations, wherein hexamer disassembly is not relevant, insulinaction after subcutaneous injection is not as fast as insulin actionwhen delivered directly to the bloodstream (e.g., by i.v. infusion).Thus, hexamer disassembly is not the only factor limiting the rate ofinsulin absorption upon subcutaneous administration.

Most models of insulin absorption assume that virtually all subcutaneousinsulin molecules are absorbed into the capillaries. However, studies insheep suggest that as much as half of insulin is, in fact, absorbedthrough the lymphatic vessels (See, Charman S, et al., (2001)Pharmaceutical Research, 18(11): 1620-1626). The lymphatic system isdesigned to facilitate reabsorption of excess fluid and large proteinsin the interstitial space. Insulin hexamers, as well as insulin dimers(which may be less readily absorbed by capillaries than monomers) may bedisproportionately shunted into lymphatic absorption. The path to andthrough the lymphatic system may be longer and involve a greater lagtime between injection and general blood circulation than does the pathdirectly to blood vessels via subcutaneous capillaries.

Various factors that may influence the rate at which insulin moleculesare absorbed into the blood from a subcutaneous depot are depicted inFIG. 3. For example, insulin absorption can be enhanced by increasingvascular uptake, either by increasing insulin concentration near bloodvessels or by increasing vascular permeability. Alternatively, insulinabsorption can be enhanced by affecting interstitial fluid pressure,either by increasing arteriole permeability or by dilating vessels.Alternatively still, insulin absorption can be enhanced by reducing theresistance to flow, such as by reducing “stickiness” of insulin in thetissue, which can be accomplished, for example, by altering theviscosity of the depot, blocking insulin binding sites, masking insulincharge, masking the charge of the tissue, disassociating aggregates,and/or dissolve or degrade the base substance of the surrounding tissueor matrix. Alternatively, reduced resistance to flow might beaccomplished by removing obstructions such as thrombus, fibrosis, orcellular debris (e.g., immune cell debris). In still other embodiments,the rate of insulin absorption is enhanced by reducing the cellularimmune response and/or reducing cellular immune damage. Dampening ofsuch biological processes in the subcutaneous space may also reduce insitu degradation and so increase the bio-availability of the injectedinsulin formulation.

In one aspect, the present invention provides a pharmaceuticalcomposition comprising an effective amount of a monomeric insulinanalogue and one or more calcium ion-chelating agents or charge-maskingagents. Without being bound by theory, masking charges in thesub-cutaneous tissue enhances migration of the monomeric insulin throughthe subcutis toward the blood vessels, particularly if the monomericinsulin has charged regions that are surface exposed. Further, andwithout being limited by theory, by promoting a transient localdisassembly of adherens junctions or tight junctions, for example in thevessel endothelium, by chelating cations (e.g., Ca²⁺), the absorption ofinsulin can be improved.

Native human insulin contains two chains, an A chain, containing 21residues and a B chain containing 30 residues. Insulin is normallystored in the pancreatic β-cell as a Zn²⁺-stabilized hexamer, butfunctions as a Zn²⁺-free monomer in the bloodstream. However, themonomer is most susceptible to fibrillation and chemical degradation,and thus insulin is generally formulated in its hexamer state with zinc,but often with mutations and/or formulation components that promotehexamer disassembly. However, even these insulin analogues (e.g.,insulin lispro) exhibit some delay for hexamer disassembly, and thusexhibit a considerable delay in onset of action and “tail” in duration.

In various embodiments, the pharmaceutical composition comprises amonomeric insulin analogue. As used herein, a “monomeric insulinanalogue” refers to an insulin that is stable for at least 30 days at25° C. when it is formulated substantially without zinc (e.g., less thanabout 0.05 moles of zinc per mole of insulin) and thus present insolution predominately in the monomeric or dimeric form as opposed tothe zinc-hexameric form. For example, the monomeric insulin analogue canbe formulated at a high concentration, such as at 100 IU/mL (e.g., aboutU100) or greater (e.g., about U200, about U300, about U400, about U500,about U1000, about U1500, or about U2000) without significant fibrilformation or chemical degradation. In various embodiments, the monomericinsulin is stable in the pharmaceutical composition for at least about 1month, or at least about 2 months, or at least about 3 months, or atleast about 4 months, or at least about 5 months, or at least about 6months, or at least about 9 months, or at least about 12 months at 25°C. without substantial formation of insulin fibrils.

As used herein, the term “about” means + or −10% of the associatednumerical value.

Accordingly, in various embodiments, the present invention contemplatesthe use of monomeric insulin analogues that have one or more mutationsthat reduce or eliminate fibril formation and/or attenuate chemicaldegradation, such as into other covalent dimer/polymer or relatedsubstances. The mutation(s) may be (independently) a natural ornon-natural (e.g., non-genetically encoded) amino acid substitutions,insertions, or deletions. It is contemplated that the mutations can beintroduced into the structure or sequence of any of the existing insulinor insulin analogues, particularly the known rapid-acting insulinproducts. For example, the mutations can be introduced into insulinanalogues such as Lispro (KP) insulin (sold under the name Humalog®),Aspart insulin (sold under the name Novalog®), Glulisine insulin (soldunder the name Apidra®), or other rapid-acting or prandial insulins,including native insulin (e.g., native human insulin).

In certain embodiments, the mutations include amino acid substitutionssuch as conservative amino acid substitutions, and/or non-conservativesubstitutions. “Conservative substitutions” include those substitutionsmade within a group of amino acids with similar side chains, forexample: the neutral and hydrophobic amino acids glycine (Gly or G),alanine (Ala or A), valine (Val or V), leucine (Leu or L), isoleucine(Ile or I), proline (Pro or P), tryptophan (Trp or W), phenylalanine(Phe or F) and methionine (Met or M); the neutral polar amino acidsserine (Ser or S), threonine (Thr or T), tyrosine (Tyr or Y), cysteine(Cys or C), glutamine (Glu or Q), and asparagine (Asn or N); basic aminoacids lysine (Lys or K), arginine (Arg or R) and histidine (His or H);and acidic amino acids aspartic acid (Asp or D) and glutamic acid (Gluor E). Further, standard amino acids may also be substituted bynon-standard amino acids, for example, those belonging to the samechemical class. By way of non-limiting example, the basic side chainlysine may be replaced by basic amino acids of shorter side-chain length(Ornithine, Diaminobutyric acid, or Diaminopropionic acid). Lysine mayalso be replaced by the neutral aliphatic isostere Norleucine (Nle),which may in turn be substituted by analogues containing shorteraliphatic side chains (Aminobutyric acid or Aminopropionic acid). Insome embodiments, the insulin analogue has from one to five mutationswith respect to the sequence of Insulin Lispro, Insulin Aspart, orFluorolog (Asp B10, ortho-monofluorophenylalanine-B24, lispro insulin).In some embodiments, these mutations are conservative mutations, with nomore than one, two, or three non-conservative mutations or non-standardmutations.

In various embodiments, the monomeric insulin analogue includes aB-chain polypeptide with mutations at positions corresponding to B24,B25, or B26 of native human insulin. For example, the monomeric insulinanalogue may include a B-chain polypeptide that incorporates ahalogenated phenylalanine substitution at position B24, B25, or B26. Inone embodiment, the halogenated phenylalanine is located at positionB24. The halogen may be fluorine, chlorine or bromine, for example. Inan embodiment, the halogenated phenylalanine at B24 is a chlorinatedphenylalanine or a fluorinated phenylalanine. In another embodiment, thehalogenated phenylalanine is ortho-monofluoro-phenylalanine(2-fluoro-phenylalanine), ortho-monobromo-phenylalanine(2-bromo-phenylalanine), ortho-monochloro-phenylalanine(2-chloro-phenylalanine), para-monofluoro-phenylalanine(4-fluoro-phenylalanine), para-monochloro-phenylalanine(4-chloro-phenylalanine), para-monobromo-phenylalanine(4-bromo-phenylalanine), or penta-fluoro-phenylalanine. In oneembodiment, the monomeric insulin analogue has 2-fluoro-phenylalanine atposition B24. In another embodiment, the monomeric insulin analogue hasa penta-fluoro-phenylalanine at position B24. These halogenated insulinanalogues are described, for example, in U.S. Patent Publication Nos.2011/0166064 and 2014/0128319, the entire contents of which are herebyincorporated by reference.

In some embodiments, the monomeric insulin analogue may include anon-standard amino-acid substitution at position B24. The non-standardamino acid may lack aromaticity. In one example, the non-standard aminoacid at position B24 may be cyclohexanylalanine, which includes anon-planar aliphatic ring system. Loss of planarity in a non-aromaticring system is associated with a change in its topographical contoursand an increase in side-chain volume relative to phenylalanine, whichmay promote hexamer disassembly.

In other embodiments, the monomeric insulin analogue may include anon-standard amino acid substitution at position B29. In one example,the non-standard amino acid at B29 is norleucine (Nle). In anotherexample, the non-standard amino acid at B29 is ornithine (Orn). Insulinanalogs including such non-standard amino acids are described, forexample, in U.S. Patent Publication No. 2014/0303076, the entirecontents of which are hereby incorporated by reference.

The monomeric insulin analogue may contain other modifications. Invarious embodiments, the insulin analogue may include one or moremutations at positions corresponding to the following positions ofnative human insulin: A3, A8, A10, A12, A13, A14, A17, and A21 of theA-chain and B2, B3, B4, B10, B13, B17, B28, and B29 of the B-chain.

In some embodiments, the monomeric insulin analogue contains asubstitution of aspartic acid (Asp or D) or lysine (Lys or K) forproline (Pro or P) at amino acid 28 of the B-chain (B28) or asubstitution of proline for lysine at amino acid 29 of the B-chain (B29)or a combination thereof. In another example, the monomeric insulinanalogue can include a substitution of lysine for asparagine at aminoacid 3 of the B-chain (B3) or a substitution of glutamic acid for lysineat amino acid 29 of the B-chain (B29) or a combination thereof.

In some embodiments, the monomeric insulin analogue comprises one ormore of the following modifications: lysine, arginine, and leucine atthe position corresponding to A3; glutamic acid, histidine, arginine,lysine, and glutamine at the position corresponding to A8; cysteine,glutamic acid, or aspartic acid at position corresponding to A10;aspartic acid or threonine at the position corresponding to A12;tryptophan, tyrosine, histidine, glutamic acid, alanine, orphenylalanine at the position corresponding to A13; histidine orglutamic acid at the position corresponding to A14; tryptophan,tyrosine, alanine, histidine, glutamic acid, glutamine, phenylalanine,or asparagine at the position corresponding to A17; glycine at theposition corresponding to A21; cysteine at the position corresponding toB2; lysine at the position corresponding to B3; cysteine at the positioncorresponding to B4; aspartic acid at the position corresponding to B10;tryptophan, tyrosine, alanine, histidine, glutamic acid, phenylalanine,asparagine, or glutamine at the position corresponding to B13;tryptophan, tyrosine, histidine, or glutamine at the positioncorresponding to B17; tryptophan, tyrosine, histidine, glutamine,aspartic acid, threonine, alanine, phenylalanine, halogenatedphenylalanine (as described above), or cyclohexanylalanine at theposition corresponding to B24; and glutamic acid at position B29. Insome embodiments, the monomeric insulin analogue includes an asparticacid at position corresponding to A10 and anortho-monofluoro-phenylalanine at position corresponding to B24.Exemplary analogs are described, for example, in U.S. Patent PublicationNo. 2014/0323398, the entire contents of which are hereby incorporatedby reference.

In various embodiments, the monomeric insulin analogue may includedeletions of one or more amino acids. In an embodiment, the monomericinsulin analogue may include a deletion of amino acids corresponding topositions B1-B3, as described for example, in International PatentPublication No. WO2014/116753, the entire contents of which are herebyincorporated by reference. In some embodiments, the monomeric insulinanalogue may include a B chain lacking amino acids B1-B3 in addition toone or more additional substitutions at A8, B24, B28, and/or B29. In anembodiment, the monomeric insulin analogue includes a B chain lackingamino acids B1-B3 and an ornithine or glutamic acid at B29.

In various embodiments, the monomeric insulin analogue may includeinsertions of one or more amino acids. In an embodiment, the insertionsare at the C-terminus. For example, the monomeric insulin analogue mayinclude an addition of at least two amino acids to the carboxyl end ofthe B-chain. In an embodiment, the B-chain includes a glutamic acid oraspartic acid insertion at position B31 and an additional insertionselected from glutamic acid, alanine, and aspartic acid at position B32.Such insulin analogues are described, for example, in U.S. Pat. No.8,399,407, the entire contents of which are hereby incorporated byreference. In various embodiments, the monomeric insulin analogue has aB-chain with the amino acid sequence Lys-Pro-Ile-Glu-Glu (KPIEE),Glu-Pro-Ile-Glu-Glu (EPIEE), Pro-Orn-Thr-Glu-Glu (POTEE), orPro-Orn-Thr-Orn (POTO) at the C-terminus. Such residues respectivelycomprise residues B28-B32, B28-32, B28-B32, and B28-B31, in whichresidues B31-B32 are C-terminal extensions of the B chain.

In some embodiments, the monomeric insulin analogue is a single-chaininsulin having an insulin A chain and an insulin B chain connected by alinker, as described, for example, in U.S. Pat. Nos. 8,192,957 and8,501,440, the entire contents of which are hereby incorporated byreference. The linker may be less than 15 amino acids long. For example,the linker may be from 4 to 12 amino acids in length, such as 4, 5, 6,7, 8, 9, or 10 amino acids in length. In an embodiment, the linker mayinclude the sequence GPRR. In various embodiments, the linker mayinclude the sequence GGGPRR, GGPRR, GSEQRR, RREQKR, RREALQKR, GAGPRR,GGGPGKR, EEGSRRSR, EEGPRR, GEGPRR, AEGSRRSR, ASGSRRSR, EEGSRRD, orEEGSRRK.

In one aspect, the present invention provides monomeric insulinformulations with calcium ion-chelating and/or charge-masking agents.Without wishing to be bound by theory, such agents can mask the chargeof the insulin or the surrounding tissue, and/or induce disassembly ofadherens junctions and/or tight junctions, to promote rapid insulinabsorption. This effect is not related to zinc chelation (and thushexamer disassembly) because the rapid absorption is observed in theabsence of zinc. Without wishing to be bound by theory, it is believedthat the calcium ion-chelating agents reduce interstitial calcium ionlevels around blood vessels, thereby promoting the disassembly ofadherens junctions and tight junctions between endothelial cells of thevessels and enhancing permeability. Alternatively or in addition, andwithout wishing to be bound by theory, the agents may mask the chargesof the tissue surrounding the insulin depot and/or the charges of theinsulin molecule itself, thereby mitigating the extent to which acharged monomeric insulin molecule becomes electrostatically bound tothe subcutaneous tissue, delaying or preventing its movement to andabsorption into vessels.

In an embodiment, the agents include one or more polycarboxylic acidcompounds. Exemplary agents include, but are not limited to,ethylenediamine tetraacetic acid (EDTA), ethylene glycol tetraaceticacid (EGTA), and cyclohexane diamino tetraacetic acid (CDTA). In anotherembodiment, the agent includes one or more anionic polysaccharides. Forexample, the agent may include alginic acid. In another embodiment, theagent includes one or more organosulfur compounds. For example, theagent may include one or more alpha lipoic acid, dimercaptosuccinic acid(DMSA), dimercaprol, and dimercaptopropane sulfonate (DMPS). In afurther embodiment, the agent includes one or more di- or tri-carboxylicacids. These agents include, for example, citric acid or oxalic acid. Ina further embodiment, the agents may include one or more benzoates.Agents may be incorporated into the formulation as salts, such as saltscomprising one or more of sodium, potassium, and magnesium cations. Inanother embodiment, the agent includes one or more of penicillamine, andextract or partial extract of chlorella and/or cilantro.

In some embodiments, the calcium ion-chelating and/or charge-maskingagent is EDTA and/or EGTA. In certain embodiments, the EDTA and/or EGTAis present in the composition within the range of about 1 to 50 mM, suchas within the range of 5 to 25 mM in some embodiments. For example, thecomposition or formulation may contain about 2 mM EDTA, about 5 mM EDTA,about 10 mM EDTA, about 15 mM EDTA, about 20 mM EDTA, or about 25 mMEDTA. In some embodiments, the composition or formulation may containabout 2 mM EGTA, or about 5 mM EGTA, or about 10 mM EGTA, or about 15 mMEGTA, or about 20 mM EGTA, or about 25 mM EGTA.

In some embodiments, the calcium ion-chelating and/or charge maskingagent is citrate or benzoate (e.g., sodium citrate or sodium benzoate).In various embodiments, the citrate or benzoate is present in theformulation at from about 1 mM to about 25 mM, such as from about 5 mMto about 20 mM, or from about 5 mM to about 15 mM, or from about 5 mM toabout 10 mM.

In some embodiments, the formulation comprises one or more organic acidshaving a pKa of from about 3 to about 6. In various embodiments, theacid is not predominately in the protonated form at physiological pH,such that the agent has a net negative charge and has the ability tomask positive charges in the subcutis. Such organic acids may be presentin the formulation at from about 1 mM to about 25 mM, such as from about5 mM to about 20 mM, or from about 5 mM to about 15 mM, or from about 5mM to about 10 mM.

In some embodiments, the pharmaceutical formulation comprises one ormore salts and/or acids sufficient to mask positive charges in thesubcutaneous tissue surrounding the insulin depot. For example, theformulation may have an ionic strength equal to or more than thatconferred by 0.9% NaCl, or equal to or more than that conferred by 120mM NaCl. For example, the formulation may have an ionic strength equalto or greater than that conferred by 150 mM NaCl, or 180 mM NaCl, or 200mM NaCl, or 250 mM NaCl.

In some embodiments, the formulation comprises human C-Peptide. HumanC-Peptide carries a net charge of −3 at neutral pH. In some embodiments,the C-Peptide is present at about 5:1 to about 1:5 with respect to theinsulin (in moles). In some embodiments, the Human C-Peptide is presentat about 2:1 to about 1:2 with respect to insulin, or is present atabout equimolar with respect to the insulin.

In still other embodiments, the pharmaceutical formulation comprises oneor more molecules with exposed surface charges (e.g., availablecharges), either positive or negative, sufficient to bindelectrostatically or otherwise (and therefore mask from insulin binding)to negatively or positively charged regions on cells, intracellularstructures, or interstitial fluid.

The pharmaceutical composition of the present invention can beformulated into any suitable form appropriate for the desired use androute of administration. For example, the pharmaceutical composition cantake the form of solutions, suspensions, emulsion, drops, tablets,pills, pellets, capsules, powders, aerosols, sprays, or any other formsuitable for administration of insulin, and for which improvements inabsorption are desired.

In some embodiments, the pharmaceutical composition is formulated forsubcutaneous administration, and may be formulated as an aqueousformulation. However, the formulations of the present invention areapplicable to various routes of administration, not limited toparenteral, intradermal, intramuscular, intranasal, sublingual,pulmonary, and oral administration. In an embodiment, the pharmaceuticalcomposition is formulated for subcutaneous administration, and isformulated for delivery using an infusion device, such as an infusiondevice described herein. Alternatively, the formulation is provided inprefilled insulin pumps or prefilled injection pens and/or single ormultiple dose vials or cartridges for subcutaneous administration. Forexample, the formulation may be provided in vials containing from 1 to20,000 bolus doses, or from 1 to about 10,000 bolus doses, or from 1 to5,000 bolus doses, or from 1 to about 1000 bolus doses, or from 1 toabout 100 bolus doses, or from 1 to about 50 bolus doses, or from 1 toabout 25 bolus doses. In some embodiments, the vial or cartridge issufficient for providing a daily, weekly, or monthly insulin requirementfor a patient. Vials may contain the doses, for example, in about 3 mlsto about 50 mls of total volume, such as from about 3 mls to about 10mls of total volume.

In various embodiments, the pharmaceutical compositions described hereinfurther include one or more pharmaceutically acceptable excipients orcarriers, the selection of which will depend on the desired route ofadministration. Further, a particular excipient may have two or morefunctions in a formulation. Table 1 below provides a list of exemplaryexcipients and their exemplary functions in a formulation.

TABLE 1 Anti- Trans - Isotonicity Preservative Buffer StabilizingSolubilizing aggregation membrane Absorption Glycerol ✓ ✓ Mannitol ✓ ✓Sorbitol ✓ ✓ Propylene glycol ✓ ✓ Phenol/m-cresol ✓ ✓ TRIS ✓ ✓ Arginine✓ ✓ ✓ ✓ Histidine ✓ ✓ ✓ Aspartic acid ✓ ✓ ✓ Glutamic acid ✓ ✓ ✓ Proline✓ Lysine ✓ Magnesium ✓ ✓ Citrate ✓ ✓ ✓ ✓ Nicotinimide ✓ ✓ Surfactants ✓✓ ✓ Alkylglycosides ✓ ✓

In various embodiments, the pharmaceutical composition includes one ormore of a pharmaceutically acceptable buffer, stabilizing agent,surfactant, solubilizing agent, charge-masking agent, anti-aggregationagent, diffusion-enhancing agent, absorption enhancing agent, andpreservative. These agents can be used in combination and functionsynergistically to, for example, enhance insulin absorption, promote amore rapid insulin pharmacokinetics, and increase insulin stability.

In certain embodiments, the pharmaceutical composition may include oneor more agents that maintain or adjust the isotonicity of theformulation. Such agents include, but are not limited to, glycerol,mannitol, sorbitol, lactose, dextrose, trehalose, sodium chloride, andpropylene glycol (see, for example, U.S. Patent Publication No.2012/0225810, the entire contents of which are hereby incorporated byreference). In various embodiments, the formulation may be hypertonic orhypotonic. For example, the pharmaceutical composition may contain oneor more agents designed to make the formulation hypertonic. Exemplaryagents include any agents that are soluble in the formulation and cannotfreely permeate the plasma membrane of cells, such as glycerin,dextrose, mannitol, NaCl, and KCl.

In certain embodiments, the pharmaceutical composition may include oneor more buffering agents for maintaining a formulation at a specific pH.Exemplary buffering agents include, but are not limited to, sodiumphosphate, arginine, TRIS (2-amino-2-hydroxymethyl-1,3-propanediol),glycylglycine, L-Histidine, HEPES, bicine, sodium acetate, sodiumcarbonate, citrate, sodium dihydrogen phosphate, disodium hydrogenphosphate, bicine, tricine, malic acid, succinate, fumaric acid,tartaric acid, aspartic acid, ethylendiamine or mixtures thereof. See,for example, U.S. Pat. No. 6,906,028 and U.S. Patent Publication No.2012/0225810, the entire contents of which are hereby incorporated byreference

In certain embodiments, the pharmaceutical composition may include oneor more stabilizing agents for stabilizing the insulin formulations.Exemplary stabilizing agents include, but are not limited to, zinc(e.g., at a molar ratio less than 0.05 to the insulin in theformulation), phenol, m-cresol, benzoate salts, TRIS, non-reducingcarbohydrates (e.g., mannitol or dextran), surfactants (e.g.,polysorbates such as TWEEN, bile salts, salts of fatty acids, orphospholipids, partial and fatty acid esters and ethers of polyhydricalcohols, of glycerol or sorbitol and of sucrose, and polyols, partialand fatty acid esters and ethers of polyhydric alcohols such as SPANpolysorbate, MYRJ, BRIJ, TRITON, and CREMOPHOR, poloxyethylene ether,and apolyethylene glycol ether), amino acids (e.g., L-Arginine,L-Glutamic acid, L-histidine, or L-methionine), alkylsaccharides (e.g.,dodecyl-(3-D-maltoside, tridecyl maltoside, tetradecyl maltoside,sucrose mono-dodecanoate, sucrose mono-tridecanoate, sucrosemono-tetradecanoate), A-L-S-L-A compounds, chromium salts, acetone,methyl ethyl ketone, propyl methyl ketone, isopropyl methyl ketone,pyruvic acid, glyoxylic acid, alpha-ketobutyric acid, alpha-ketoglutaricacid, acetoacetic acid, pyridoxal, and pyridoxal pyrophosphate, singlyor in combination.

In certain embodiments, the pharmaceutical composition may include oneor more solubilizing agents to avoid precipitation of the insulin orinsulin analogue within a formulation and to enhance solubility of theinsulin or insulin analogue. Exemplary solubilizing agents include, butare not limited to, L-Arginine, L-arginine analogues or di- andtri-peptides containing arginine, guanidine, magnesium, alcohols,alcohol esters of organic acids, nitrogen-containing solvents,phospholipids, acetic acid, ascorbic acid, citric acid, glutamic acid,aspartic acid, succinic acid, fumaric acid, maleic acid, adipic acid,agmatine, 4-guanidinobenzoic acid, guanidoacetic acid, guanidinosuccinicacid, and co-polyamino acids, singly or in combination.

In certain embodiments, the pharmaceutical composition may include oneor more anti-aggregation agents to avoid insulin aggregation insolution. Exemplary anti-aggregation agents include, but are not limitedto, arginine, polysorbate 20, histidine, proline or proline derivatives,sulfobutyl ether-β-cyclodextrin, the tripeptide HTD, argininium ion orlysine, and propylene glycol, citric acid, and nicotinamide.

In certain embodiments, the pharmaceutical composition may include oneor more transmembrane agents for facilitating the permeation anddiffusion of insulin or an insulin analogue through membranes. Exemplarytransmembrane agents include, but are not limited to, acetic acid,ascorbic acid, citric acid, glutamic acid, aspartic acid, succinic acid,fumaric acid, maleic acid, and adipic acid, singly or in combination.

In certain embodiments, the pharmaceutical composition may include oneor more absorption enhancing agents for facilitating the absorption ofinsulin or insulin analogue by any of a variety of mechanisms. Exemplaryabsorption enhancing agents include, but are not limited to, surfactants(e.g., bile salts, salts of fatty acids, or phospholipids), nicotinicagents (e.g., nicotinamide, nicotinic acid, niacin, niacinamide, vitaminB3 and any salts thereof), pancreatic trypsin inhibitor, magnesiumsalts, poly-unsaturated fatty acids, didecanoyl phosphatidylcholine,aminopolycarboxylate, tolmetin, sodium caprate, salicylic acid, oleicacid, linoleic acid, EPA, DHA, benzylic acid, NO donors (e.g.,3-(2-Hydroxy-1-(1-methylethyl)-2-nitrosohydrazino)-1-propanamine,N-ethyl-2-(1-ethyl-hydroxy-2-1-nitrosohydrazino)-ethanamine, orS-nitroso-N-acetylpenicillamine), a bile acid, a glycine-conjugated formof a bile acid, sodium ascorbate, potassium ascorbate, sodiumsalicylate, potassium 5 salicylate, acetyl-salicylic acid,salicylosalicylic acid, aluminum acetylsalicylate, choline salicylate,salicylamide, lysine acetylsalicylate, exalamide, diflunisal, andethenzamide, singly or in combination.

In certain embodiments, the pharmaceutical composition may include oneor more diffusion enhancing agents such as base-substance diffusionenhancing agents. Exemplary diffusion enhancing agents include, but arenot limited to, glycosaminoglycanases (e.g., hyaluronidase).

In certain embodiments, the pharmaceutical composition may include oneor more preservatives for preventing growth of microorganisms. Exemplarypreservatives include, but are not limited to, phenol, meta-cresol,methylparaben, and sodium benzoate.

In various embodiments, the pharmaceutical composition may include oneor more vasodilation agents, anti-inflammatory agents, anti-thromboticagents, anti-degradation agents, insulin-binding antagonist,anti-fibrotic agents, anti-oxidants, anti-proliferatives, nerve-calmingagents, and antibiotics. These agents can be used in combination withany other excipients and agents described herein and may functionsynergistically to, for example, enhance insulin absorption, promote amore rapid insulin pharmacokinetics, and increase stability of insulinor insulin analogue.

For example, the pharmaceutical composition may include one or morevasodilation agents that increase fluid flow in a region. Exemplaryvasodilation agents include, but are not limited to, nitric oxide (NO)donors (e.g., nitroglycerin, isosorbide dinitrate, isosorbidemononitrate, amyl nitrate, erythrityl, tetranitrate, and nitroprusside),histamine, 2-methylhistamine, 2-(2-pyridyl)ethylamine,2-(2-thiazolyl)ethylamine, 4-methylhistamine, papaverine, minoxidil,dipyridamole, hydralazine, adenosine, GPLC and other embodiments ofL-carnitine, arginine, prostaglandin D2, adenosine triphosphate, uridinetrisphosphate, potassium salts, and, in certain circumstances, α1 and α2receptor antagonists (e.g., Prazosin, Phenoxybenzamine, Phentolamine,Dibenamine, and Tolazoline), Betazole, Dimaprit, β2 Receptor Agonists(e.g., Isoproterenol, Dobutamine, Albuterol, Terbutaline, Aminophylline,Theophylline, Caffeine, and Calcium channel blockers (e.g., Amlodipine,Aranidipine, Azelnidipine, Barnidipine, Benidipine, Cilnidipine,Clevidipine, Isradipine, Efonidipine, Felodipine, Lacidipine,Lercanidipine, Manidipine, Nicardipine, Nifedipine, Nilvadipine,Nimodipine, Nisoldipine, Nitrendipine, Prandipine), singly or incombination.

The pharmaceutical composition may include one or more anti-inflammatoryagents. Without wishing to be bound by theory, it is believed that theanti-inflammatory agents reduce cellular immune response andconsequently, limit the production of oxidative enzymes, certainvasoconstrictive enzymes, cytokines and insulin-degrading proteases nearthe infusion site, the accumulation of cellular debris, as well as theformation of connective tissue capsules around infusion catheters.Anti-inflammatory agents can also limit down-regulation of eNOS andnNOS, thereby facilitating the maintenance of bioavailable NO withaccompanying local vasodilation. Exemplary vasodilation agents include,but are not limited to, thiocarbonates or cryptolepine analogues,immunosuppressants (e.g., cyclosporine, tacrolimus, andsirolimus/rapamycin), toradol, cromolyn sodium, cortisol,methylprednisolone, prednisone, dexamethasone, acetylcysteine,salicylates (e.g., acetylsalicylic acid, diflunisal, salsalate, cholinemagnesium trisalicylate, sodium salicylate, magnesium salicylate,trolamine salicylate, methyl salicylate), propionic acid derivatives(e.g., ibuprofen, dexibuprofen, naproxen, fenoprofen, ketoprofen,dexketoprofen, flurbiprofen, oxaprozin, loxoprofen), acetic acidderivatives (e.g., indomethacin, tolmetin, sulindac, etodolac,ketorolac, diclofenac, aceclofenac, nabumetone), enolic acid derivatives(e.g., Piroxicam, Meloxicam, Tenoxicam, Droxicam, Lornoxicam, Isoxicam),Fenamic acid derivatives (e.g., Mefenamic acid, Meclofenamic acid,Flufenamic acid, Tolfenamic acid), COX-2 inhibitors (e.g., Celecoxib,Rofecoxib, Valdecoxib, Parecoxib, lumiracoxib, Etoricoxib, Firocoxib),sulphonanilides (e.g., Nimesulide), licofelone, H-harpagide, Lysineclonixinate, doxorubicin, and tamoxifen, singly or in combination.

The pharmaceutical composition may include one or more anti-thromboticor fibrinolytic agents. Without wishing to be bound by theory, it isbelieved that anti-thrombotic agents inhibit the coagulation cascade andenhance thrombolysis, thereby reducing thrombus mass that can blockfluid flow near any infusion site. Exemplary anti-thrombotic orfibrinolytic agents include, but are not limited to, antithrombinsI-III, heparin, warfarin, anisindione, danaparoid, argatroban,lepirudin, bivalirudin, fondaparinux, drotecogin alfa, tissueplasminogen activator (TPa), streptokinase, and urokinase, singly or incombination.

The pharmaceutical composition may include one or more anti-degradationagents. Such agents can reduce insulin degradation in a depot, stabilizeinsulin's intermolecular bonds, and/or prevent unfolding and amyloidosisof insulin. Exemplary anti-degradation agents include, but are notlimited to, aprotinin and human pancreatic trypsin inhibitor,antiretrovirals (e.g., saquinavir, ritonavir, indinavir, nelfinavir,amprenavir, lopinavir, atazanavir, fosamprenavir, tipranavir, anddarunavir), velcade, alphal-proteinase inhibitor, doxycycline,Trehalose, L-arginine, L-glycine, L-histidine, glycylglycine,nicotinamide, HP-βCD and cyclodextran derivatives, singly or incombination. In an embodiment, the anti-degradation agent is selectedfrom aprotinin or trehalose.

The pharmaceutical composition may include one or more insulin-bindingantagonists. Without wishing to be bound by theory, it is believed thatsuch agents may block potential low-affinity binding sites insubcutaneous tissues which would otherwise slow insulin's diffusion froma depot. Exemplary insulin-binding antagonists include, for example,insulin analogs which have minor modifications to their protein sequencewhich render them functionally inactive (e.g., Leu-A3 insulin).

The pharmaceutical composition may include one or more charge-maskingagents. Without wishing to be bound by theory, it is believed that suchagents may block electrostatic binding sites in subcutaneous tissue thatwould otherwise slow insulin's diffusion from a depot. Exemplarycharge-masking agents include, for example, weak or strong acids orbases, and ionic salts.

The pharmaceutical composition may include one or more anti-fibroticagents. Such agents may block the elaboration of extracellular matrix byfibroblasts. Further still, such agents may block the formation of orenhance the degradation of fibrous capsules around infusion catheters.Exemplary anti-fibrotic agents include, but are not limited to, matrixmetalloproteinases (e.g., collagenase-1-3 and -4, gelatinase A and B,stromelysin-1, -2 and -3, transin-1, matrilysin, elastase and others),tamoxifen, fibrinolytic agents such as fibrinolysin, tissue plasminogenactivators (e.g., alteplase, retaplase and tenecteplase), streptokinase(e.g., natural streptokinase and anistreplase) and urokinase (e.g.,Abbokinase®).

The pharmaceutical composition may include one or more anti-oxidants.Such agents may counter the pro-inflammatory and/or insulin-degradingeffects of oxygen-derived free radicals generated by oxidative enzymes.Exemplary anti-oxidants include, but are not limited to, GPLC (glycinepropionyl-l-carnitine), acetylcarnitine, L-carnitine and other entitiescomprising L-cartinine, Pentoxifylline, Ascorbic acid, Retinol,Ubiquinone, Melatonin, glutathione and respective derivatives and AlphaLipoic Acid. In an embodiment, the anti-oxidant is selected from GPLC(Glycine propionyl-l-carnitine), acetylcarnitine, L-carnitine, or otherL-cartinine containing compounds, Ascorbic acid, Melatonin, orglutathione and respective derivatives, singly or in combination.

The pharmaceutical composition may include one or moreanti-proliferatives. Without wishing to be bound by theory, it isbelieved that anti-proliferatives may prevent local proliferation ofleukocytes, smooth muscle cells, fibroblasts and other immune or repaircells, thereby, reducing the number of cells that would otherwise be inthe area of an infusion-catheter-related injury where such cells would,among other things, excrete extracellular matrix that could obstructblood vessel or interstitial fluid flow and/or contribute toencapsulation of the catheter tip. Exemplary anti-proliferativesinclude, for example, plavopiridol and paclitaxel.

The pharmaceutical composition may include one or more nerve-calmingagents that reduce local nerve signaling that may otherwise present as alocal site reaction. Exemplary nerve-calming agents include, but are notlimited to, magnesium sulfate, Lidocaine, Bupivicaine, Etidocaine,Isoflurane, Halothane, Sevoflurane, Desflurane, Enflurane, procaine,benzocaine, chloroprocaine, cocaine, cyclomethycaine,dimethocaine/larocaine, piperocaine, propoxycaine, procaine/novocaine,proparacaine, tetracaine/amethocaine, articaine, cinchocaine/dibucaine,levobupivacaine, lignocaine, mepivacaine, prilocaine, ropivacaine,trimecaine, saxitoxin, neosaxitoxin, tetrodotoxin, menthol, eugenol, andpost ganglionic adrenergic blockade agents (e.g., guanethidine andbretylium), singly or in combination. In an embodiment, thenerve-calming agent is magnesium sulfate, Lidocaine, Bupivacaine, orropivacaine.

The pharmaceutical composition may further include one or moreantibiotics. Exemplary antibiotics include, but are not limited to,preservatives (included at higher than normal levels), amikacin,gentamicin, kanamycin, neomycin, netilmicin, tobramycin, paromomycin,spectinomycin, geldanamycin, herbimycin, rifaximin, streptomycin,loracarbef, ertapenem, doripenem, imipenem/cilastatin, meropenem,cefadroxil, cefazolin, cefalotin or cefalothin, cefalexin, cefaclor,cefamandole, cefoxitin, cefprozil, cefuroxime, cefixime, cefdinir,cefditoren, cefoperazone, cefotaxime, cefpodoxime, ceftazidime,ceftibuten, ceftizoxime, ceftriaxone, cefepime, ceftaroline fosamil,ceftobiprole, teicoplanin, vancomycin, telavancin, clindamycin,lincomycin, daptomycin, azithromycin, clarithromycin, dirithromycin,erythromycin, roxithromycin, troleandomycin, telithromycin, spiramycin,aztreonam, furazolidone, nitrofurantoin, linezolid, posizolid,radezolid, torezolid, amoxicillin, ampicillin, azlocillin,carbenicillin, cloxacillin, dicloxacillin, flucloxacillin, mezlocillin,methicillin, nafcillin, oxacillin, penicillin g, penicillin v,piperacillin, temocillin, ticarcillin, amoxicillin/clavulanate,ampicillin/sulbactam, piperacillin/tazobactam, ticarcillin/clavulanate,bacitracin, colistin, polymyxin b, ciprofloxacin, enoxacin,gatifloxacin, levofloxacin, lomefloxacin, moxifloxacin, nalidixic acid,norfloxacin, ofloxacin, trovafloxacin, grepafloxacin, sparfloxacin,temafloxacin, mafenide, sulfacetamide, sulfadiazine, silversulfadiazine, sulfadimethoxine, sulfamethizole, sulfamethoxazole,sulfanilimide (archaic), sulfasalazine, sulfisoxazole,trimethoprim-sulfamethoxazole(co-trimoxazole) (tmp-smx),sulfonamidochrysoidine(archaic), demeclocycline, doxycycline,minocycline, oxytetracycline, tetracycline, clofazimine, dapsone,capreomycin, cycloserine, ethambutol, ethionamide, isoniazid,pyrazinamide, rifampicin, rifabutin, rifapentine, streptomycin,arsphenamine, chloramphenicol, fosfomycin, fusidic acid, metronidazole,mupirocin, platensimycin, quinupristin/dalfopristin, thiamphenicol,tigecycline, tinidazole, and trimethoprim, singly or on combination.

In various embodiments, the pharmaceutical composition may also includeone or more peptide agents that open tight junctions, for example, forpulmonary and intestinal applications. Such peptide agents include, butare not limited to, zonula occludens toxin (ZOT), zonulin, or thepeptide FCIGRL (see, for example, U.S. Patent Publication Nos.2008/0014218 and 2007/0196272, and U.S. Pat. Nos. 8,557,763 and8,728,491, the entire contents of all of which are incorporated hereinby reference).

In various embodiments, the pharmaceutical composition of the presentinvention may include any of the agents described herein at aconcentration well below the minimum systemic effect level. In someembodiments, the combination of one or more agents described herein hassynergistic effects in, for example, enhancing insulin absorption,promoting a more rapid insulin pharmacokinetics, and increasing insulinstability. Table 2 below lists exemplary dosing ranges for some of theagents.

TABLE 2 Agent Systemic Dose Range Excipient Dose Range Prazosin 0.5-40mg/day 0.09-144 μg/day Phenoxybenzamine 20-120 mg/day 1-120 μg/dayPhentolamine 5 mg/day 1-20 μg/day Dibenamine 161-420 mg/day 32.2-1680μg/day Tolazoline 40-200 mg/day 8-800 μg/day Chlorpromazine 30-400mg/day 1.92-51.2 μg/day Haloperidol 1-15 mg/day 0.12-36 μg/dayPapaverine HCl 30-960 mg/day 6 to 3840 μg/day Sodium nitroprusside210-7000 μg/day 0.042-28 μg/day KCl up to 29.8 g/day 2.98-59.6 mg/dayATP up to 5.04 g/day 1.008-20.16 mg/day PGD2 (prostaglandin D2) up to51.6 mg/day 10.32-206.4 μg/day Isosorbide dinitrate 40-60 mg/day 6-120μg/day Isosorbide mononitrate 20-60 mg/day 4 to 240 μg/day L-arginine 30g/day 6-120 mg/day Hydralazine 200-300 mg/day 15.2-456 μg/day Adenosine6-30 mg/day 1.2-6 μg/day Dipyridamole 300-400 mg/day 12-240 μg/dayDiazoxide 210-1050 mg/day 42-4200 μg/day Minoxidil 5-40 mg/day 0.9-360μg/day Histamine 1.925-2.8 mg/day 0.385-11.2 μg/day Bradykinin 30-90mg/day 5.82-349.2 μg/day GPLC (Glycine propionyl-l- 1500 mg/day 48-960μg/day carnitine) Nitroglycerine 0.4-1.2 mg/day 0.0308-1.848 μg/dayErythrityl tetranitrate 30-50 mg/day 6-200 μg/day Isoproterenol0.02-0.26 mg/day 0.004-1.04 μg/day Dobutamine 50.4-4032 mg/day10.08-16128 μg/day Albuterol 6-32 mg/day 8-86.4 μg/day Terbutaline0.25-3 mg/day 0.05-12 μg/day Aminophylline up to 1125 mg/day 0.225-4.5mg/day Theophylline up to 900 mg/day 0.18-3.6 mg/day Caffeine 65-1200mg/day 13-4800 μg/day Amlodipine 5-10 mg/day 0.77-30.8 μg/dayAranidipine 5-20 mg/day 0.18-14.4 μg/day Azelnidipine 8-16 mg/day0.288-5.76 μg/day Barnidipine 5-20 mg/day 0.145-11.6 μg/day Benidipine2-8 mg/day 0.072-5.76 μg/day Cilnidipine 5-20 mg/day 0.18-14.4 μg/dayClevidipine 24-504 mg/day 4.8-2016 μg/day Isradipine 5 to 20 mg/day 1 to74 μg/day Efonidipine 20-60 mg/day 0.72-43.2 μg/day Felodipine 2.5-10mg/day 0.0825-6.6 μg/day Lacidipine 2-8 mg/day 0.074-5.92 μg/dayLercanidipine 10-30 mg/day 0.2-12 μg/day Manidipine 10-20 mg/day0.96-38.4 μg/day Nicardipine 60-120 mg/day 4.2-168 μg/day Nifedipine30-60 mg/day 2.7-108 μg/day Nilvadipine 8-16 mg/day 0.264-10.56 μg/dayNimodipine 360 mg/day 9.36-187.2 μg/day Nisoldipine 17-34 mg/day0.17-6.8 μg/day Nitrendipine 10-80 mg/day 0.46-73.6 μg/day Pranidipine1-4 mg/day 0.036-2.88 μg/day Guanethidine 10-100 mg/day 0.53-106 μg/dayBretylium 350-700 mg/day 210-11200 μg/day DMSO 7-15 g/day 1.4-104 mg/dayMannitol 50-200 g/day 10-800 mg/day Albumin 1.75-3.5 g/day 0.35-14mg/day Tamoxifen 20 mg/day 4-80 μg/day Polysorbate 80 n/a 0.005-1672μg/day Polysorbate 20 n/a .002-224 μg/day Streptokinase 1500000 IU/day300-6000 IU/day Streptodornase n/a 25-500 U/day Urokinase 308000 IU/day61-1232 IU/day rtPA 15-90 mg/day 3-360 μg/day Hyaluronidase 300 U/mlAcetylcysteine 10.5 g/day 2.1-42 mg/day Dnase 2.5 mg/day 0.075-1.5μg/day Chymotrypsin Collagenase 2.32 mg/ml 0.46-9.28 μg/ml Fibrinolysin2.5 mg/ml .5-10 μg/ml MMPs Heparin 5,000-20,000 u 1-80 u Dexamethasone0.5-9 mg/day 0.1-36 μg/day Cortisol 100-500 mg/day 20-2000 μg/daySolumedrol 10-40 mg 2-160 μg/day Medrol 4-48 mg/day 0.72-172 μg/dayLidocaine 50-100 mg 10-400 μg Bupivicaine 7.5-10.5 mg 1.5-42 μg Procaine50-100 mg 10-400 μg/day Etidocaine 560 mg/day 0.112-2.24 mg/dayRopivican 5-200 mg 1-800 μg/day Mepivican 400 mg-1000 mg/day 80-4000μg/day Aprotinin 10,000-500,000 KIU/day 2-2000 KIU/day AcetylsalicyticAcid 1-3 g/day 0.2-12 mg/day Nicotinamide 0.05-500 mg/day 0.01-2000μg/day Toradol 3-120 mg/day 6-480 μg/day Sodium Salicylate 560 mg/day0.112-2.24 mg/day Magnesium salicylate 460-3600 mg/day 0.092-14.4 mg/dayTrolamine salicylate Methyl salicylate Cromolyn Sodium 800-2800 mg/day1.6-112 μg/day Ciclosporin 3-10 mg/day 0.042-2.8 mg/day Tacrolimus700-3500 μg/day 0.14-14 μg/day Sirolimus (rapamycin) 2 mg/day 0.06-1.2μg/day GPLC (Glycine propionyl-l- 1500 mg/day 0.3-6 mg/day carnitine)Pentoxyphilline 1200 mg/day 0.24-4.8 mg/day Ascorbic acid 0.1-2 g/day0.2-8 mg/day Retinol 700 to 900 μg/day 0.112-2.88 μg/day Ubiquinone 1200mg/day 240-4800 μg/day Melatonin 2 mg/day 0.2-4 μg/day Alpha LipoicAcid, 600-1200 mg/day 0.12-4.8 mg/day Paclitaxel (Taxol) 135 mg/m²0.027-0.54 mg/m²

In various embodiments, the pharmaceutical composition does not includezinc, or contains less than 0.05 moles of zinc per mole of insulin.

It will be appreciated that the actual dose of the insulin or monomericinsulin analogue or dimeric insulin analogue to be administeredaccording to the present invention will vary according to, for example,the particular dosage form and the mode of administration, as well asthe patient's disease.

Individual doses of the insulin or monomeric insulin analogue or dimericinsulin analogue can be formulated at, for example, about 1 U/ml (1insulin unit per ml) to about 2000 U/ml, or about 1 U/ml to about 1000U/ml, or about 1 U/ml to about 500 U/ml, or about 1 U/ml to about 400U/ml, or about 1 U/ml to about 300 U/ml, or about 1 U/ml to about 200U/ml, or about 1 U/ml to about 100 U/ml, or about 1 U/ml to about 50U/ml, or about 1 U/ml to about 10 U/ml. In some embodiments, theformulation contains from 1 U to about 100 U per bolus administration,such as about 1 U to about 20 U in some embodiments (e.g., about 5 U,about 10 U, about 12 U, or about 15 U).

In various embodiments, the pharmaceutical composition of the presentinvention provides an onset of insulin activity (e.g., which can bemeasured as ½ T_(max)—early) of less than about 40 minutes afteradministration, or less than about 30 minutes, or less than about 20minutes, or less than about 15 minutes, or less than about 10 minutes,or less than about 5 minutes after administration in variousembodiments.

In various embodiments, the pharmaceutical composition provides a rapidinsulin absorption profile as measured by, for example, C_(max) and/orT_(max). As used herein, C_(max) is the maximum or peak concentration ofa drug observed after its administration. As used herein, T_(max) is thetime at which maximum concentration (C_(max)) occurs. In certainembodiments, the pharmaceutical composition reaches a T_(max) at lessthan about 120 minutes, or less than about 90 minutes, or less thanabout 60 minutes, or less than about 50 minutes, or less than about 40minutes, or less than about 30 minutes, or less than about 20 minutes,or less than about 15 minutes after administration.

In various embodiments, the pharmaceutical composition provides a shortduration of insulin activity. In certain embodiments, the pharmaceuticalcomposition provides a duration of insulin activity of about 5 hours orless, about 4 hours or less, about 3 hours or less, or about 2 hours orless after administration. In a further embodiment, the pharmaceuticalcomposition provides a duration of insulin activity of from about 1 to 2hours after administration. In some embodiments, duration of activity ismeasured as the time to which insulin action subsides to less than ½maximal activity.

In exemplary embodiments, the pharmaceutical composition uponsubcutaneous injection provides an onset of insulin activity (e.g.,measured as ½ T_(max)) in about 30 minutes or less or in about 20minutes or less, with a duration of activity of about 2 hours or less.

In various embodiments, the pharmaceutical composition provides enhancedstorage stability. In certain embodiments, the pharmaceuticalcomposition is stable for at least about 1 month, or at least about 3months, or at least about 6 months, or at least about 12 months, or atleast about 18 months, or longer, at 25° C. without substantialformation of insulin fibrils.

In further embodiments, the pharmaceutical composition maintains atleast about 60% potency, about 70% potency, about 80% potency, about 90%potency, or about 95% potency after six months at 25° C. In anotherembodiment, the pharmaceutical composition maintains at least about 60%potency, about 70% potency, about 80% potency, about 90% potency, orabout 95% potency after 9 months at 30° C. In a further embodiment, thepharmaceutical composition maintains at least about 60% potency, about70% potency, about 80% potency, about 90% potency, or about 95% potencyafter 12 months at 25° C.

In one aspect, the present invention provides devices that enable theinfusion of pharmaceutical formulations, including insulin or insulinanalogues, or other pharmaceuticals, such that the infusion exhibitsenhanced pharmaceutical properties such as more rapid pharmacokinetics(e.g., rapid onset of action, and/or shorter duration). In anembodiment, the present invention provides devices that enhance thesubcutaneous infusion and absorption of pharmaceutical formulations suchas insulin or insulin analogues into the circulation from a subcutaneousdepot. Without wishing to be bound by theory, it is believed that theinfusion devices of the present invention enhance active agent diffusionfrom the injection depot to both blood and lymphatic vessels andincrease the rate at which the active agent is absorbed into thesevessels. In some embodiments, the invention improves the uptake ofactive agent by blood vessels as opposed to lymphatic vessels.

In various embodiments, the present invention provides an infusion setfor use with pharmaceutical formulations, and one or more energydelivery systems, such as an ultrasound transducer, a tactor, and/or anelectrophoresis electrode. In some embodiments, the pharmaceuticalformulation is an insulin formulation, which may include any insulin orinsulin analogue known in the art and/or as described herein. In anembodiment, the insulin formulation for use with the infusion setexhibits rapid hexamer disassembly, as compared to native human insulin.In another embodiment, the insulin formulation is a substantiallyzinc-free formulation of a stable monomeric or dimeric insulin analogueformulation. In a further embodiment, the insulin formulation includesany of the insulin pharmaceutical compositions as described herein.

In some embodiments, the agent is a protein, peptide, oligonucleotide,or small molecule active agent that is not rapidly absorbed uponsubcutaneous injection. In some embodiments, the active agent is anantibody or antigen-binding portion thereof, or is a cytokine or growthfactor. In some embodiments, such as those that employ electrophoresisin the infusion set, the active agent has a net negative charge of atleast −2 or a net positive charge of at least +2.

In various embodiments, the infusion set includes a first body, anadhesive surface, a subcutaneous infusion catheter, and one or moreenergy delivery systems selected from an ultrasound transducer, atactor, and an electrophoresis electrode. The infusion set may includeadditional companion devices that enable the easy placement or insertionof the infusion catheter into the skin.

In various embodiments, the infusion set includes a first body to whichother pieces may be connected. In an embodiment, the body is made up ofa plastic, such as a semi-rigid plastic.

In various embodiments, infusion set includes an adhesive surface. Theadhesive surface holds the infusion set onto the surface of the skin.

In various embodiments, the infusion set includes a catheter. Morespecifically, the infusion set includes a subcutaneous infusioncatheter. In an embodiment, the catheter runs from the first bodythrough the plane of the adhesive surface, through the dermis, and intothe subcutis. In an embodiment, the catheter projects about 1 mm toabout 10 mm into the subcutis. For example, the catheter may projectabout 3 mm, about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm,or about 10 mm into the subcutis. In an embodiment, the catheterprojects about 7 mm into the subcutis. The catheter can be made ofvarious materials, including but not limited to Teflon or metal.

The infusion set may further include a supply tube or a port to which asupply tube can be connected. The supply tube, when connected, is incontinuous fluid communication with the infusion catheter such that theactive agent (e.g., insulin) can be pumped through the supply tube intothe catheter. In various embodiments, an active agent reservoir can beconnected and disconnected to the supply tube.

In certain embodiments, infusion set is operably connected to a pump anda controller operably connected to an active agent (e.g., insulin)reservoir for delivering active agent through the supply tube to thecatheter. The pump includes a pumping mechanism such as a step,electromechanical, electrochemical, chemical, or other motor that drivesa rotary piston, a compression bladder, syringe, or other mechanism. Thecontroller typically contains a microprocessor, a control algorithm, andan interface display, which are optionally contained in the first body.The controller may further include one or more external user controlsand/or a communication interface, which are optionally contained in thefirst body. For example, the controller may include one or more inputcontrols such as buttons, optionally an external input port, optionallya wireless communications interface, and one or more actuator interfacesdesigned to drive the pumping mechanism and possibly other devices.

In certain embodiments, the reservoir is included in a second body whichcan be detached from the first body. In such embodiments, an adhesivesurface may be located on the second body. In an embodiment, the secondbody also includes the infusion catheter. The second body can bereplaced from time to time as active agent needs replenishing.

In some embodiments, the infusion set comprises an ultrasoundtransducer. In some embodiments, the ultrasound transducer is a lowintensity ultrasound (LITUS) transducer. In other embodiments, theinfusion set comprises a tactor, such as a low-frequency piezoelectrictactor. In some embodiments, the transducer or the tactor is positionedabove the distal end of the infusion catheter. In other embodiments, thetransducer or the tactor is placed at some other location within thebody of the infusion set. In some embodiments, the transducer or thetactor is contained within the first body. For example, the body of theinfusion set may have a first body (1) which contains the transducer orthe tactor (3) and a second body that is connected to the adhesivesurface and infusion catheter (2). FIGS. 7A and 7B.

In various embodiments, the transducer or the tactor are energyefficient, using for example, about 1 μW, about 10 μW, about 0.1 mW, orabout 1 mW, or about 10 mW of power. For example, the transducer or thetactor may be powered by a battery that powers the pump. Optionally, thetransducer or the tactor are driven by a signal generator in the pump,which is controlled by the pump. Alternatively, the transducer or thetactor are powered by a rechargeable battery in the infusion set itself,are driven by a signal generator in the infusion set itself, and/or arecontrolled by a switch on the infusion set or by wired or wirelessremote control (for example, over Bluetooth, Zigbee, or other wirelessprotocols).

In some embodiments, the ultrasound transducer emits a signal within therange of about 0.1 MHz to about 5 MHz, about 0.2 to about 3 MHz, about0.2 to about 2.5 MHz, about 0.2 to about 2 MHz, about 0.2 to about 1.5MHz, about 0.2 to about 1 MHz, about 0.2 to about 0.5 MHz, about 0.5 toabout 3 MHz, about 0.5 to about 2.5 MHz, about 0.5 to about 2 MHz, about0.5 to about 1.5 MHz, about 0.5 to about 1 MHz, about 1 MHz to about 2MHz, or about 1 MHz to about 1.5 MHz, inclusive of all values and rangestherebetween. For example, the ultrasound transducer may emit a signalof about 0.1 MHz, about 0.2 MHz, about 0.3 MHz, about 0.4 MHz, about 0.5MHz, about 0.6 MHz, about 0.7 MHz, about 0.8 MHz, about 0.9 MHz, about1.0 MHz, about 1.5 MHz, about 2.0 MHz, about 2.5 MHz, about 3.0 MHz,about 3.5 MHz, about 4.0 MHz, about 4.5 MHz, or about 5.0 MHz, inclusiveof all values and ranges therebetween.

In some embodiments, the piezoelectric tactor emits a signal with afrequency of less than about 2 kHz, or less than about 1 kHz, such asfrom about 0.1 kHz to about 1.0 kHz. In an embodiment, the piezoelectrictactor emits a signal with a frequency of less than about 1 kHz. Withoutwishing to be bound by theory, it is believed that such a low-frequencytactor can reproduce the effects of vibrational massage on an infusionsite.

Different frequencies resonate with different tissues (for example, 1mm² fat lobules may have a characteristic frequency of about 170 kHz).Accordingly, in an embodiment, the transducers may be driven at avariety of frequencies and in different patterns. In an embodiment, thetransducer or the tactor produces square waves, which produce multipleharmonics. In another embodiment, the transducer or the tactor producesa saw tooth wave or other forms which may have more motive effect. Invarious embodiments, the transducer or the tactor may deliver a signalcontinuously. In other embodiments, the transducer or the tactor maydeliver a pulsed signal (for example, 10% off and 90% on; 20% off and80% on; 30% off and 70% on; 40% off and 60% on; or 50% on and 50% off),which may be more effective in relatively static tissues. In variousembodiments, the transducer or the tactor operates at a low power level,a moderate power level, or at a high power level.

The ultrasound or tactor may operate before, during, and/or afterinsulin infusion.

In various embodiments, the adhesive surface is ultrasonicallytransmissive, particularly in embodiments where an ultrasound ispositioned in the first body above the second body that contains theinsulin reservoir and adhesive surface.

In some embodiments, the infusion set comprises an electrophoresiselectrode. As demonstrated herein, applying an electric field to aninsulin depot can cause the insulin to migrate through a gel at a rateof between 1 and 2 mm/min, depending on the charge of the insulin.Without wishing to be bound by theory, it is believed the electric fieldcan draw insulin up towards the deep vascular plexus in the dermis justabove the subcutis where the insulin can be more rapidly absorbed. Invarious embodiments, the infusion set can draw insulin to the capillaryrich vascular plexus in 5 minutes or less when the distal end of theinfusion set of less than 6 mm below the dermis.

In an embodiment, and as shown in FIGS. 8A and 8B, the infusion set maycomprise at least two electrophoresis electrodes. In an embodiment, thefirst electrophoresis electrode (4) is proximal to the distal end of theinfusion catheter. In some embodiments, the first electrophoresiselectrode is connected to the voltage source partly by one or moreconductive metal or plastic wires imbedded in or attached to the inneror outer surface of the infusion catheter lumen. In some embodiments,the entire infusion catheter lumen is conductive or is comprised of aconductive lumen coated on one or more surfaces with an insulating filmor by an insulating lumen. In some embodiments, the electrode on thedistal end is at least 1 mm long and may encompass the entirecircumference of the lumen. Alternatively, there may be multipleinfusion catheter electrodes placed along the infusion catheter. In oneembodiment, the infusion catheter lumen may be perforated along itslength to allow the infusate to escape from the lumen other than fromthe distal end.

In an embodiment, the second electrophoresis electrode (5) is on theskin surface. Optionally, the second electrophoresis electrode isattached to the adhesive surface. FIG. 8C. The second electrophoresiselectrode may have a coating designed to increase conductivity to theskin such as a biocompatible, electrochemical gel or adhesive. In anembodiment, the second electrophoresis electrode may be positioned abovethe distal end of the infusion catheter. FIG. 8C. In another embodiment,the skin-surface second electrophoresis electrode forms a pattern, suchas a ring or a square or a series of discontinuous shapes around thepoint where the infusion catheter enters the dermis (FIG. 9). In anotherembodiment, the skin-surface second electrophoresis electrode is locatedsome distance from the infusion catheter. In another embodiment, all orpart of the adhesive surface is electrically conductive and serves as anelectrode. In an alternate embodiment, the skin-surface electrode isabove the skin surface and not in direct contact with the skin.

In various embodiments, the first and second electrophoresis electrodesare connected to opposite ends of a voltage source (6). In anembodiment, the first electrophoresis electrode is a cathode and thesecond electrophoresis electrode is an anode. In other embodiments, thefirst electrophoresis electrode is an anode and the secondelectrophoresis electrode is a cathode. The actual selection will bebased on, for example, the charge of the active agent. In an embodiment,the electrodes are connected by an electrical conductor to an interfaceplug designed for easy connection or disconnection to or from thevoltage source. In various embodiments, the voltage source provides aconstant voltage. The voltage may be in the range of about 0.1 volt toabout 20 volts, about 0.1 volt to about 19 volts, about 0.1 volt toabout 18 volts, about 0.1 volt to about 17 volts, about 0.1 volt toabout 16 volts, about 0.1 volt to about 15 volts, about 0.1 volt toabout 14 volts, about 0.1 volt to about 13 volts, about 0.1 volt toabout 12 volts, about 0.1 volt to about 11 volts, about 0.1 volt toabout 10 volts, about 0.1 volt to about 9 volts, about 0.1 volt to about8 volts, about 0.1 volt to about 7 volts, about 0.1 volt to about 6volts, about 0.1 volt to about 5 volts, about 0.1 volt to about 4 volts,about 0.1 volt to about 3 volts, or about 0.1 volt to about 2 volts,inclusive of all values and ranges therebetween. In an embodiment, thevoltage is in the range of about 1 volt to about 15 volts or about 1volt to about 10 volts. In an embodiment, the voltage is about 1 volt,about 2 volts, about 3 volts, about 4 volts, about 5 volts, about 6volts, about 7 volts, about 8 volts, about 9 volts, about 10 volts,about 11 volts, about 12 volts, about 13 volts, about 14 volts, about 15volts, about 16 volts, about 17 volts, about 18 volts, about 19 volts,or about 20 volts, inclusive of all values and ranges therebetween.

In an embodiment, the voltage source is powered by the battery in theinsulin pump and controlled by the pump. In this embodiment, the voltagesource is connected to the infusion set by wires that run along or areimbedded in the insulin supply tube. In alternate embodiments, thevoltage source is powered by a rechargeable battery in the infusion setitself and/or is controlled by a switch on the infusion set or by wiredor wireless remote control (for example, over Bluetooth, Zigbee, WiFi,or other wireless protocols). In one embodiment, the voltage source andcontroller is contained in a second, reusable body which fits togetherwith a first, disposable body which is connected to the adhesivesurface, infusion catheter, and electrodes and which has an interfacemechanism to ensure proper connection between the lumens and wires ofthe first and second bodies.

In an embodiment, voltage can be turned on just before or at the time ofbolus infusion and be turned off manually or under timed or remotecontrol after 0.5, 1, 1.5 or 2 hours or some other amount of time. In apreferred embodiment, this on-off control would be controlled by thepump, either directly through an actuator interface or indirectlythrough a wireless connection.

In an embodiment, the voltage source negative terminal is connected tothe first electrophoresis electrode. In an embodiment, the voltageapplied is regulated so as to produce between about 0.2 and about 5.0 mAof current.

The electrophoresis electrodes can be made of any conductive material ormaterial doped to be conductive. In an embodiment, the electrophoresiselectrodes include a conductive coating. The conductive coating mayfurther include a material with anti-microbial characteristics. In anembodiment, the conductive coating may include a silver-containingcompound with anti-microbial characteristics. Further still, it has beendiscovered that the electric field generated by the current between theelectrophoresis electrodes of the present invention has antifouling andantimicrobial effects. Thus, in one embodiment, the electric currentbetween the electrodes is sufficient to create a bioelectric effect.

In various embodiments where an electrode is contained in the first bodyabove the second body having the adhesive surface, the second body andthe adhesive surface are electrically conductive.

In an embodiment, the infusion set of the present invention furtherincludes an insulin reservoir. In a still further embodiment, theinfusion set of the present invention further includes a catheterinsertion device. In an alternate embodiment, the first electrophoresiselectrode can be positioned proximal to, positioned distant from, orintegrated with a sensor, such as a glucose sensor, which is alsoresident on the infusion catheter. In another embodiment, the electrodecan extend beyond the end of the infusion catheter lumen or be mountedon a component that extends beyond the end of the lumen. In an alternateembodiment, the infusion catheter could be replaced or supplemented byan electrophoresis electrode placed separately from the infusioncatheter into the subcutaneous tissue.

In various embodiments, the ultrasound transducer, tactor, orelectrophoresis system may be used to enhance the absorption ofrapid-acting insulin, or basal insulin, or both.

In various embodiments, the various components of the infusion set asdescribed herein have synergistic effects in, for example, facilitatinginsulin absorption and promoting a more rapid insulin pharmacokinetics.For example, the insulin infusion set of the invention may include acombination of an ultrasound transducer, a tactor, and/or anelectrophoresis electrode, which produce synergistic effects in, forexample, enhancing insulin absorption.

One of the challenges associated with the use of infusion sets andinfusion catheters is maintaining long-term patency. Currently, the FDArequires that infusion sets be replaced every 2-3 days. This is becauseof the risks of catheter occlusion due to the presence of fibrouscapsules generated by the body's immune response. The fibrotic capsulesmay impede the diffusion of insulin and or the flow of infusate. Furtherstill, inflammatory cascades and the corresponding cellular immuneresponse, triggered by tissue damage and wounds caused by catheterplacement and post-placement movement can lead to the accumulation ofcellular debris around the catheter and impede the flow of insulin fromthe catheter. Further still, the risks for infection around the area ofcatheter placement also increase with time of use. In addition toenhancing absorption of insulin, in some embodiments the invention alsoprovides for infusion sets that last longer than 3 days, such as atleast about 5 days, or at least about 1 week, or at least about 2 weeks,or at least about 1 month.

Accordingly, in various embodiments, the pharmaceutical composition ofthe present invention restricts the clotting cascade to mitigate theformation of thrombus, limits the cellular immune response, and reducesfibrosis resulting in enhanced catheter patency. The pharmaceuticalcomposition of the present invention also impedes the growth ofmicroorganisms such as bacteria and fungi in the catheter placementwound so as to reduce infection. For example, the pharmaceuticalcomposition of the present invention reduces the burning, irritation,and inflammation around the site of catheter placement.

Specifically, various agents may be added to the pharmaceuticalcomposition of the present invention to promote catheter patency and/orenhance insulin absorption from the wound surrounding a catheter.

In certain embodiments, agents that increase blood flow through adiposetissue capillaries and venuoles may be included in the pharmaceuticalcomposition. These agents include α₂ and α₁ receptor blockade agentssuch as Prazosin, Phenoxybenzamine, Phentolamine, Dibenamine,Tolazoline, Chlorpromazine, and Haloperidol. In an embodiment, agentsthat directly relax arteriolar and/or venous smooth muscle may beincluded. Such agents include, but are not limited to, Hydralazine withor without cutaneous blood flow, Adenosin, Dipyridamole, Diazoxide,Minoxidil, Papaverine, Nitroprusside, Prazosin, Histamine, Bradykinin,Nitroglycerine, Isosorbide Dinitrate, Amyl Nitrite, Erythrityl, andTetranitrate. In an embodiment, a B₂ receptor agonist such asIsoproterenol, Dobutamine, Albuterol, Terbutaline, Aminophylline,Theophylline, or Caffeine may be included (singly or in combination). Inan embodiment, a calcium channel inhibitor may be included. Suchinhibitors include, but are not limited to, Amlodipine (Norvasc),Aranidipine (Sapresta), Azelnidipine (Calblock), Barnidipine (HypoCa),Benidipine (Coniel), Cilnidipine (Atelec, Cinalong, Siscard) Clevidipine(Cleviprex), Isradipine (DynaCirc, Prescal), Efonidipine (Landel),Felodipine (Plendil), Lacidipine (Motens, Lacipil), Lercanidipine(Zanidip), Manidipine (Calslot, Madipine), Nicardipine (Cardene, CardenSR), Nifedipine (Procardia, Adalat), Nilvadipine (Nivadil), Nimodipine(Nimotop), Nisoldipine (Baymycard, Sular, Syscor), Nitrendipine (Cardif,Nitrepin, Baylotensin), and Pranidipine (Acalas), singly or incombination. In an embodiment, an agent that blocks postganglionicadrenergic nerves (e.g., Guanethidine, Bretylium) may be included. In anembodiment, an agent that decreases oxygen, decreases pH, and increasescarbon dioxide in local tissues may be included. It is believed thatsuch agents may increase endothelium-derived nitric oxide,non-esterified fatty acids, prostaglandins and adenosine thus causingarteriolar dilation. In an embodiment, an agent that activates α₁ and B₁receptors on adipose cells may be included. In addition, thepharmaceutical composition of the invention may be administered inconjunction with, for example, approaches that increase cardiac outputand total blood flow such as exercise, and in connection with localheating or other energy delivery designed to increase local blood flow.

In certain embodiments, agents that increase absorption throughcapillary and venuole walls into plasma may be included in thepharmaceutical composition. It is believed that these agents functionsto enhance insulin uptake by capillaries, venuoles, and lymphatics. Inan embodiment, agents that increase capillary and venuole permeabilityare included. Such agents include, for example, H₁ receptor agonistssuch as Histamine, 2-Methylhistamine, 2-(2-Pyridyl)ethylamine, and2-(2-Thiazolyl)ethylamine and H₂ receptor agonists such as4-Methylhistamine, Betazole, and Dimaprit, singly or in combination. Inan embodiment, a higher insulin concentration may be employed toincrease insulin concentration gradient from tissue to plasma. In afurther embodiment, agents that increase hydrostatic pressure withintissue fluid may be used. Such agents include, for example, 3%Hypertonic saline, Histamine, Mannitol, Albumin, and Dextran. In anotherembodiment, agents that decrease osmotic pressure within tissue fluidmay be used.

In certain embodiments, agents that increase active agent (e.g.,insulin) diffusion may be included in the pharmaceutical composition.These agents can be used to minimize blood clot density, dissolvefibrin, DNA, and extracellular matrix connective tissue (collagen,elastin, hyaluronic acid) within granulation tissue while not affectingthe biological activity of insulin. By way of non-limiting example,these agents include, Hyuronidase, Acetylcysteine, Streptokinase,Streptodornase, Urokinase, Recombinant Tissue Plasminogen Activator,Deoxyribonuclease, Chymotrypsin, Collagenase, Fibrinolysin,Deoxyribonuclease, Matrix Metalloproteinases, Heparin, andglucocorticoids such as Dexamethasone, Cortisol, Solumedrol, and Medrol,singly or in combination.

In certain embodiments, agents that increase the flow of active agent(e.g., insulin) into the lymphatic vessels may be included in thepharmaceutical composition. These agents increase the flow of activeagent from the granulation tissue surrounding the infusion catheter tothe lymphatic vessels. In an embodiment, agents that increasehydrostatic pressure within tissue fluid may be included. These agentsinclude, for example, Histamine, 2-3% hypertonic saline, Urea, andGlucose. Other agents for rendering the formulation hypertonic includeglycerin, dextrose, mannitol, NaCl, and KCl, as well as other mentionedperviously. In an embodiment, agents that increase water content withinthe tissue fluid may be included. These agents include, for example,water, histamine, and 2-3% hypertonic saline. In another embodiment,agents that increase lymph flow by increasing muscle movement and minuteventilation may be included.

In certain embodiments, agents that minimize active agent (e.g.,insulin) degradation may be included in the pharmaceutical composition.Without wishing to be bound by theory, it is believed that such agentsinhibit the activities of neutrophils, monocytes, macrophages,lymphocytes, and platelets which accumulate within the granulationtissue following tissue trauma and release proteases, lipases, oxygenradicals, IL-1, IL-6, IL-8, MCP-1, and TNF that degrade insulinsurrounding the infusion catheter. These agents include, but are notlimited to, glucocorticoids such as Dexamethasone, Cortisol, Solumedrol,and Medrol, anesthetic such as Lidocaine, Bupivicaine, Procaine,Etidocaine, Ropivican, Mepivican, Isoflurane, Halothane, Sevoflurane,Desflurane, and Enflurane, aprotinin or traysylol, aspirin andnon-steroidal anti-inflammatory drugs (NSAIDs), cromolyn sodium, andimmunosuppressant drugs such as Ciclosporin, Tacrolimus, and Sirolimus,singly or in combination.

In certain embodiments, agents that promote the wound healing processmay be included in the pharmaceutical composition. In an embodiment,anti-inflammatory agents that inhibit, for example, the activities ofeicosanoids may be included. These agents include, but are not limitedto, aspirin and NSAIDs, anti-inflammatory cytokines, glucocorticoids,cyclosporines, Tacrolimus (Prograf), Sirolimus (rapamycin, Rapamune),Bradykinin, Adenosine, Nitric Oxide (NO), Matrix Metalloproteinases(MMPs), Exopeptidases (e.g., Aminopeptidase, Dipeptidase, Dipeptidylpeptidase, Tripeptidyl peptidase, Angiotensin-converting enzyme, Serinetype carboxypeptidases: Cathepsin A, Metallocarboxypeptidases:Carboxypeptidase, Metalloexopeptidase) Endopeptidase (e.g., Serineproteases, Cysteine protease, Aspartic acid protease,Metalloendopeptidases, Secretase), and Deoxyribonucleases, singly or incombination.

In some aspects, the invention provides methods of treating orpreventing a condition in a patient, by administering an active agent(e.g., insulin or other active agent) using an infusion set describedherein. In some embodiments, the present invention provides methods fortreating a subject with diabetes or other condition treated withrapid-acting insulins, using any of the pharmaceutical compositions orformulations including insulin or insulin analogues as described herein.The present invention also provides methods of treating a subject withdiabetes using any of the insulin infusion sets for delivering rapidaction insulin formulations as described herein. In an embodiment, thesubject has type 1 diabetes and/or type 2 diabetes. In some embodiments,the patient exhibits insulin resistance. In a further embodiment, thesubject has gestational diabetes. In certain embodiments, the subject isundergoing a regimen of basal insulin. The basal insulin may beadministered from one to three times daily as a bolus injection, or isadministered by continuous infusion. The continuous infusion may be ofany of the pharmaceutical compositions or formulations including insulinor insulin analogues described herein, and it may utilize any of theinfusion sets described herein.

Optionally, the subject may suffer from a metabolic disease for whichinsulin administration can be beneficial, such as obesity or metabolicsyndrome. As used herein, the term “metabolic disease” refers to a groupof identified disorders in which errors of metabolism, imbalances inmetabolism, or sub-optimal metabolic homeostasis occur.

In an embodiment, the metabolic disease is obesity. For example, thesubject may suffer from central obesity. In some embodiments, theobesity is one of simple obesity (alimentary obesity; usually resultingfrom consumption of more calories than the body can utilize), secondaryobesity (usually resulting from an underlying medical condition, suchas, for example, Cushing's syndrome and polycystic ovary syndrome), andchildhood obesity. In some embodiments, the obesity is classified as:Class I, which includes a BMI between 30 and 34.99; Class II, whichincludes BMIs of 35 to 39.99; and Class III, which includes a BMI ofover 40. Further, the present invention provides for obesity of any ofclasses I, II, or III that is further classified as severe, morbid, andsuper obesity.

In a further embodiment, the present invention provides methods oftreating a subject who is prediabetic using any of the pharmaceuticalcompositions, formulations, or infusion sets including insulin asdescribed herein. Prediabetes, also referred as impaired fasting glucose(IFG) or impaired glucose tolerance (IGT), is a precursor condition totype 2 diabetes. Prediabetes is diagnosed when fasting plasma glucose isbetween 100 to 125 mg/dL (5.56-6.94 mmol/L); or plasma glucose level isbetween 140 to 199 mg/dL (7.78-11.06 mmol/L) at 2-hours post-glucoseload of 75 g; or an A₁C level between 5.7 and 6.4%. Without interventionand appropriate treatment, people with prediabetes are at risk fordeveloping type 2 diabetes.

In a further embodiment, the present invention provides a method oftreating a subject with diabetes by administering one of thepharmaceutical compositions or formulations described herein through aninfusion set, where the infusion set is replaced every 3rd day, or every4th day, or every 5th day, or every 6th day, or every 7th day, or every8th day, or every 9th day, or every 10th day, or every 11th day, orevery 12th day, or every 13th day, or every 14th day, or every 15th day,or every 16th day, or every 17th day, or every 18th day, or every 19thday, or every 20th day, or every 21 day, or every 22 day, or every 23day, or every 24th day, or every 25th day, or every 26th day, or every27th day, or every 28th day, or every 29th day, or every 30th day, orevery 31st day.

The pharmaceutical composition, formulation, and/or infusion set may beused to administer insulin before or during a meal. Due to the rapidabsorption, the delivered insulin can shut off the conversion ofglycogen to glucose in the liver, thereby preventing hyperglycemia. Inan embodiment, the pharmaceutical composition, formulation, and/orinfusion set are used to administer rapid action insulin at less thanabout 60 minutes, less than about 50 minutes, less than about 40minutes, less than about 30 minutes, less than about 20 minutes, lessthan about 15 minutes, less than about 10 minutes, or less than about 5minutes before a meal, or about the time of commencing a meal. In anembodiment, the pharmaceutical composition, formulation, and/or theinfusion set are used for administering insulin within about 10 minutesto about 20 minutes of commencing a meal (e.g., before or aftercommencing a meal).

In various embodiments, the pharmaceutical composition or formulation isadministered with or without an infusion set at least one time, at leasttwo times, at least three times, at least four times, at least fivetimes or more daily in connection with meals. In an embodiment, thepharmaceutical composition or formulation is administered (with orwithout an infusion set) at least three times daily in connection withmeal consumption. In certain embodiments, the pharmaceutical compositionor formulation is administered (or delivery is activated) upon symptomsof hyperglycemia.

In certain embodiments, the pharmaceutical composition or formulation isadministered (with or without an infusion set) as a bolus subcutaneousinjection. For example, administration may be achieved through a singlebolus subcutaneous injection. In an embodiment, the pharmaceuticalcomposition or formulation is administered through an infusion system,such as the infusion system as described herein for delivering rapidaction insulin. In some embodiments, the pharmaceutical composition,formulation, and/or infusion set automatically administer rapid-actinginsulin upon a detection of low blood glucose levels. The low bloodglucose levels may be detected by a sensor proximal to or distant froman insulin infusion system such as the insulin infusion set as describedherein.

In some embodiments, the volume of the pharmaceutical composition orformulation administered varies. In some embodiments, the volume of therapid acting insulin composition delivered by the insulin infusion setvaries. In various embodiments, the injectate volume is less than about2 ml, less than about 1.9 ml, less than about 1.8 ml, less than about1.7 ml, less than about 1.6 ml, less than about 1.5 ml, less than about1.4 ml, less than about 1.3 ml, less than about 1.2 ml, less than about1.1 ml, less than about 1.0 ml, less than about 0.9 ml, less than about0.8 ml, less than about 0.7 ml, less than about 0.6 ml, less than about0.5 ml, less than about 0.4 ml, less than about 0.3 ml, less than about0.2 ml, or less than about 0.1 ml, or less than about 90 μl, or lessthan about 80 μl, or less than about 70 μl, or less than about 60 μl, orless than about 50 μl, or less than about 40 μl, or less than 30 μl, orless than about 20 μl, or less than about 10 μl, or less than about 9μl, or less than about 8 μl, or less than about 7 μl, or less than about6 μl, or less than about 5 μl, or less than about 4 μl, or less thanabout 3 μl, or less than about 2 μl, or less than about 1 μl, or lessthan about 0.5 μl, or less than about 0.1 μl, inclusive of all valuesand ranges therebetween.

Administration of the pharmaceutical composition or formulation may beaccompanied by the use of one or more of low intensity ultrasound(LITUS), mechanical massage, and electrophoresis. A combination of theseapplications is believed to provide synergistic effects in, for example,enhancing the speed of insulin absorption into the circulation and/orpromoting a more rapid insulin pharmacokinetics. In an embodiment, theultrasound, mechanical message, and/or electrophoresis are applied forat least about 4 hours, at least about 3 hours, at least about 2 hours,at least about 1.5 hours, at least about 60 minutes, at least about 50minutes, at least about 40 minutes, at least about 30 minutes, at leastabout 20 minutes, at least about 10 minutes, or at least about 5 minutesafter bolus infusion. In an embodiment, the ultrasound, mechanicalmessage, and/or electrophoresis are applied for at least about 60minutes after bolus infusion. In another embodiment, the ultrasound,mechanical message, and/or electrophoresis are applied for at leastabout 30 minutes before and/or after bolus infusion. In a furtherembodiment, the ultrasound, mechanical message, and/or electrophoresisare applied about 10 minutes before and/or after bolus infusion. Theultrasound, mechanical message, and/or electrophoresis may automaticallyoperate for a predetermined amount of time. Alternatively, theultrasound, mechanical massage, or electrophoresis may be turned offbased on an algorithm, which may optionally trace blood glucose levelsas an input. Alternatively, the ultrasound, mechanical message, and/orelectrophoresis may be turned off manually by the subject.

In an embodiment, the infusion set may be placed on the epidermis and bereplaced about every: ¼ day, ½ day, ¾ day, 1 day, 1.5 days, 2 days, 2.5days, 3 days, 3.5 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days,10 days, 11 days, 12 days, 13 days, 14 days, 15 days, 16 days, 17 days,18 days, 19 days, 20 days, 21 days, 22 days, 23 days, 24 days, 25 days,26 days, 27 days, 28 days, 29 days, or 30 days.

In an embodiment, the subject may receive the pharmaceutical compositionor formulation with or without a basal insulin composition as controlledby an artificial pancreas system, which may further comprise a glucosesensor. For example, the subject may receive the rapid acting insulincomposition delivered by the infusion set upon detection ofhyperglycemia by the glucose sensor, and the subject may also receiveperiodic administrations (e.g., 1 to 3 times daily) of a long-actingbasal insulin composition, all controlled by the artificial pancreassystem.

Where a basal insulin is delivered, in some embodiments the basalinsulin is infused at a daily dose of about 10 U to about 500 U ofinsulin, such as about 10 U to about 100 U of insulin.

The present invention is further illustrated by the followingnon-limiting examples.

EXAMPLES Example 1 Euglycemic Clamp Studies using Insulin Formulationswith a Calcium Ion Chelator

Euglycemic clamp studies were conducted on Yorkshire pigs to study thepharmacodynamics (PD) of insulin absorption. On the day of study, eachanimal underwent anesthesia with isoflurane and was endotracheallyintubated. Oxygen saturation and end-tidal expired CO₂ were continuouslymonitored. To block endogenous pancreatic α- and β-cell secretion, pigswere given i.v. octreotide acetate before beginning the clamp andcontinuously thereafter. IV catheters were placed and baselineeuglycemia established with 10% dextrose infusion.

A s.q. injection of the test formulation was given in the nape of theneck: skin was pinched and the needle inserted 0.8 mm before theinjection was made.

A variable-rate glucose infusion (GIR) was given to maintain bloodglucose (BG) at approximately 85 mg/dl for 3-4 hours until the GIRreturned to pre-insulin baseline. A computerized protocol for glucoseclamping was used. 2-ml blood samples for insulin assay were obtainedaccording to the following schedule: from 0-40 min after insulindelivery, 5-minute intervals; from 50-140 min, 10-minute intervals; andfrom 160 min—to the point when GIR was back to baseline, 20-minintervals.

For each of the analyses, the fitted curve, not the raw data, was used.GIR was graphed, and curve parameters calculated: time to half-maximaleffect (early), time to half-maximal effect (late), time to maximaleffect, and area-under-the-curve (AUC) over baseline.

Formulations of Fluorolog (Asp B10, orthomonofluorophenylalanine-B24,lispro insulin) in a zinc free phosphate buffer (which is an insulinanalog that is stable in a zinc-free formulation) was administered atU100 (N=4) and U400 (N=2) concentrations with (N=2) and without (N=4) 5mM EDTA. The onset of insulin action (determined as the time until theGIR was half way to its peak) was twice as fast in the formationscontaining EDTA as in those that did not. FIG. 4.

Example 2 Euglycemic Clamp Studies using Energy Delivery

Euglycemic clamp studies were conducted on Sinclair pigs to study thepharmacokinetics (PK) and pharmacodynamics (PD) of insulin absorption.On the day of study each animal underwent anesthesia with isoflurane andwas endotracheally intubated. Oxygen saturation and end-tidal expiredCO₂ were continuously monitored. To block endogenous pancreatic α- andβ-cell secretion, pigs was given i.v. octreotide acetate beforebeginning the clamp and continuously thereafter. IV catheters wereplaced and baseline euglycemia established with 10% dextrose infusion.

A ZetrOZ UltrOZ low intensity ultrasound (LITUS) therapy device wasturned on and placed over the injection site for 30 minutes prior toinjection (FIG. 5). The UltrOZ device is about 4 cm in diameter,designed for veterinary use, and delivers LITUS at 3 MHz at an energyconcentration of about 50 mW/cm2 near the injection site. A s.q.injection of humalog was given in the nape of the neck: skin was pinchedand the needle inserted 0.8 mm before the injection is made. The devicewas replaced after the injection and left in place for the remainder ofthe procedure. To verify that this exposure to LITUS does not contributeto insulin degradation, a sample of Humalog was exposed to thisintensity of LITUS for 48 hours at 37° C., after which no evidence ofchemical degradation by HPLC or visual fibril formation was detected.

A variable-rate glucose infusion (GIR) was given to maintain BG atapproximately 85 mg/dl for 3-4 hr until the GIR returned to pre-insulinbaseline. The computerized protocol for glucose clamping was used. 2-mlblood samples for insulin assay were obtained according to the followingschedule: from 0-40 min after insulin delivery, 5-minute intervals; from50-140 min, 10-minute intervals; and from 160 min—to the point when GIRwas back to baseline, 20-min intervals.

For each of these analyses, the fitted curve, not the raw data, wasused. GIR was graphed, and curve parameters calculated: time tohalf-maximal effect (early), time to half-maximal effect (late), time tomaximal effect, and area-under-the-curve (AUC) over baseline.

These studies showed that a more rapid PK and more rapid onset of PD(FIG. 6) were achieved when the injection site was exposed toultrasound.

Example 3 Insulin Movement in an Electrical Field

To assess the effect of using electrophoresis to accelerate thediffusion of s.q. administered insulin in a target direction through ahydrogel medium like those found in the septae of the s.q. tissue, therate movement of various insulin analogs were tested in an acrylamidegel under 0.5 mA/cm current for 15 minutes, which is standard forcommercial iontophoresis devices. Insulin analogs with a variety of netcharges were tested. In addition to Humalog®, we also tested Asp-B10ortho-monofluorophenylalanine-B24, lispro insulin (Fluorolog), Glu-B31Glu-B32 insulin (Hexalog-1) and Glu-A8 Glu-B31 Glu-B32 insulin(Hexalog-2), which are significantly more negatively charged than humaninsulin. The results (Table 3) suggest that insulin is highly mobileunder a physiologically tolerable electric field and that morenegatively charged insulin analogs are even more mobile.

TABLE 3 Migration in acrylamide gel at pH 7 of insulin analogs under 0.5mA/cm for 15 min Insulin Distance % of Analog Charge (cm) Lispro Lispro−2 1.5 100 Fluorolog −3.3 1.8 120 Hexalog-1 −4 2.2 146 Hexalog-2 −5 2.6173

Example 4 Insulin Movement in Tissue

The effect of an electric field was explored on migration through thesubcutis using fresh porcine abdominal skin tissue obtained from localabattoirs. To do this, a modified Franz apparatus was developed thatcould test up to 12 samples simultaneously (FIGS. 12A, 12B).Full-thickness porcine skin tissue plugs that were three cm in diameterwere placed subcutis-down in individual wells over reservoirs containingcathodes below 2 ml of test solution. The device was then inverted torun the experiments.

Tissue and test solution were maintained at 37° C. using a heat lamp andmonitored with a digital thermometer probe placed between the plexiglassplates, adjacent to the tissues. Anodes were inserted into conductivepaste placed on the epidermal surface. Utilizing multipleelectrophoresis power sources, 10V or 20V of electromotive potential wasthen run across each cathode-anode pair for one hour. Current typicallystarted at approximately 20 mA typically fell over time to about 5 mAlikely due to ion depletion. Current tended to be higher in wellsreceiving 20 volts vs. those receiving 10 V. We settled on NiChrome(80/20 Nickel/Chromium) electrodes, which were stable and produced onlyminor and occasional discoloration.

We tested the apparatus using a solution of bromophenol blue (BPB), a0.67 kDa dye that appears blue above pH 4.6 and carries a negativecharge near neutral pH similar to that of insulin. We were able todemonstrate significant migration of the dye when the voltage was on vs.when it was off (FIG. 13). The epidermal surface was dark blue involtage-treated tissue. An edge view showed that dye penetrated throughthe subcutis in voltage-treated tissue (but not in 0 V). Thisdemonstrates migration of charged chemicals through subcutaneous tissue.

We next conducted pilot experiments using Cyanine-5-labeled insulin(Cy5-insulin, P/N IS1-S5-1, Nanocs, Inc.): human insulin conjugated tocyanine-5-NHS-ester, a fluorophore with MW of 619 Da that excitesoptimally at 647 nm and emits with peak energy at 662 nm. Each insulinmolecule in Cy5-insulin is labeled with 2-7 fluorophore units accordingto the manufacturer. Assuming a normal distribution of fluorophorelabeling efficiency, about 2% of the insulin molecules will have 1functional fluorophore unit. Cy5 at neutral pH has a net +1 charge andinsulin has a net −2 charge at neutral pH, so the average overall chargeof the single-labeled Cy5-insulin should be negative, resulting inmigration to the anode.

FIG. 14 shows the Cy5-insulin distribution in a thin section exposed toCy5-insulin (0.62 U insulin/ml) during an applied 10-volt differentialfor 2 hours. Following one hour of electrophoresis, the tissues wereremoved, bisected through the center of the skin disk in a planeperpendicular to the epidermal surface, placed in 4% paraformaldehyde(pH 7.4) for 18-24 hrs and subsequently transferred to 30% sucrose untilembedded in OCT. From each frozen OCT block, 14-μm sections were cut,mounted on microscope slides and imaged through a 10× objective on aNikon deconvolution brightfield-epifluorescence microscope fitted with acube filter appropriate for Cy5 absorption and emission spectra and acharge-coupled device (CCD) digital camera. The bright-field (BF) imageshows the full skin thickness with epidermis on the left and subcutis onthe right. Cy5 label can be seen to exist predominantly in the subcutis,but has also penetrated to the dermis and epidermis, indicatingmigration of the fluorescence-tagged insulin through the full skinthickness

We then conducted experiments using unlabeled insulin lispro. Migrationof unlabeled insulin lispro was detected by immunohistochemistry (IHC)and processed according to a protocol similar to that described abovefor the Cy5-insulin experiment. One microscope slide was stained withH&E; an adjacent slide was stained with a Guinea pig polyclonal antibody(Ab) (Abcam ab7842), which was detected by a goat anti-Guinea pigpolyclonal IgG H&L (Alexa Fluor® 594; Abcam ab150188). Microscopicimages from this experiment are shown in FIG. 15 and demonstrate insulinmigration though tissue under the influence of an electric field.

Example 5 Enhanced Insulin Absorption Through Formulation

In five studies in Yucatan swine, various formulations of insulinanalogue T-0339 were injected subcutaneously and the effect of insulinaction were monitored by the glucose infusion rate required to maintaineuglycemia. T-0339 has an A chain with the amino acid sequence:GIVEQCCESICSLYQLENYCN and a B chain with the amino acid sequence:FVNQHLCGSDLVEALYLVCGERGXFYTPET, where X isortho-monofluorophenylalanine. T-0339 has three disulfide linkages whichare identical to human insulin, i.e., two inter-chain disulfide bondsconnecting A7 to B7 and A20 to B19 and one intra-chain disulfide bondconnecting A6 to A11.

T-0339 is negatively charged (−3) and when formulated in a Tris buffertook 90 minutes to reach half-peak potency. However, when excess molarquantities of EDTA (20 mM), Citrate (20 mM), and EDTA (10 mM)+Citrate(8.6 mM) were added to the formulation, the time to half-peak potencywas reduced significantly. EDTA and Citrate are both negatively chargedions (−4 and −3 respectively) and it is hypothesized that thesemolecules take the place of insulin in positively charged electrostaticbinding sites in the subcutaneous tissue, allowing the monomeric insulinto move more freely to the vessels for rapid absorption. The combinedeffect of EDTA and citrate was not synergistic in this study. See FIG.16. Formulations consisted of 50 mM Tris, 3.2 mg/ml m-cresol andglycerin adjusted to maintain equivalent tonicity (0.8-0.9% NaClequivalent).

FIGS. 17 to 19 show additional studies: FIG. 17 shows T_(max) ½ early;FIG. 18 shows AUC ½ late, and FIG. 19 shows T_(max) ½ late. Excipientsinclude EDTA, citrate, and sodium benzoate.

Equivalents

While the invention has been described in connection with specificembodiments thereof, it will be understood that it is capable of furthermodifications and this application is intended to cover any variations,uses, or adaptations of the invention following, in general, theprinciples of the invention and including such departures from thepresent disclosure as come within known or customary practice within theart to which the invention pertains and as may be applied to theessential features hereinbefore set forth and as follows in the scope ofthe appended claims.

Those skilled in the art will recognize, or be able to ascertain, usingno more than routine experimentation, numerous equivalents to thespecific embodiments described specifically herein. Such equivalents areintended to be encompassed in the scope of the following claims.

INCORPORATION BY REFERENCE

All patents and publications referenced herein are hereby incorporatedby reference in their entireties.

What is claimed is:
 1. A pharmaceutical composition comprising aneffective amount of a monomeric insulin analogue or dimeric insulinanalogue and one or more calcium ion-chelating agents.
 2. Apharmaceutical composition comprising an effective amount of a monomericinsulin analogue or dimeric insulin analogue and an effective amount ofone or more charge-masking agents sufficient to mask charges insubcutaneous tissue.
 3. The pharmaceutical composition of claim 1 or 2,wherein the composition is an aqueous formulation.
 4. The pharmaceuticalcomposition of claim 3, wherein the composition is formulated forsubcutaneous or intra-dermal administration.
 5. The pharmaceuticalcomposition of any one of claims 1 to 4, wherein the compositioncomprises less than 0.05 moles of zinc per mole of insulin.
 6. Thepharmaceutical composition of any one of claims 1 to 5, wherein thecalcium ion-chelating agent or charge-masking agent(s) comprise one ormore amino polycarboxylic acid compounds.
 7. The pharmaceuticalcomposition of claim 6, wherein the calcium ion-chelating orcharge-masking agent(s) comprise one or more of ethylenediaminetetraacetic acid (EDTA), ethylene glycol tetraacetic acid (EGTA), andcyclohexane diamino tetraacetic acid (CDTA), and wherein the agent isoptionally a sodium or magnesium salt.
 8. The pharmaceutical compositionof any one of claims 1 to 5, wherein the calcium ion-chelating or chargemasking agent(s) comprise an anionic polysaccharide.
 9. Thepharmaceutical composition of claim 8, wherein the calcium ion-chelatingor charge-masking agent(s) comprise alginic acid.
 10. The pharmaceuticalcomposition of any one of claims 1 to 5, wherein the calciumion-chelating or charge-masking agent(s) comprise one or moreorganosulfur compounds.
 11. The pharmaceutical composition of claim 10,wherein the calcium ion-chelating agent or charge-masking agentscomprises one or more of alpha lipoic acid, dimercaptosuccinic acid(DMSA), dimercaprol, and dimercaptopropane sulfonate (DMPS).
 12. Thepharmaceutical composition of any one of claims 1 to 5, wherein thecalcium ion-chelating or charge-masking agent(s) comprise one or moredi- or tri-carboxylic acids.
 13. The pharmaceutical composition of claim12, wherein the calcium ion-chelating or charge-masking agent(s)comprise citric acid or oxalic acid.
 14. The pharmaceutical compositionof any one of claims 1 to 5, wherein the calcium ion-chelating agent(s)comprise one or more of penicillamine, and extract or partial extract ofchlorella and/or cilantro.
 15. The pharmaceutical composition of any oneof claims 1 to 5 wherein the charge-masking agent is a benzoate salt.16. The pharmaceutical composition of any one of claims 1 to 15, whereinthe composition provides an onset of insulin activity of less than about40 minutes after subcutaneous administration.
 17. The pharmaceuticalcomposition of claim 16, wherein the composition reaches T_(max) at lessthan about 120 minutes after administration.
 18. The pharmaceuticalcomposition of claim 17, wherein the composition provides a duration ofinsulin activity of about 5 hours or less.
 19. The pharmaceuticalcomposition of claim 18, wherein the composition provides a duration ofinsulin activity of from 1 to 2 hours.
 20. The pharmaceuticalcomposition of any one of claims 1 to 19, wherein the monomeric insulinanalogue is formulated at about U10 to about U500.
 21. Thepharmaceutical composition of any one of claims 1 to 20, wherein thecomposition is stable for at least about one month at 25° C. withoutsubstantial formation of insulin fibrils.
 22. The pharmaceuticalcomposition of claim 21, wherein the composition maintains at leastabout 90% potency after six months at 25° C.
 23. The pharmaceuticalcomposition of claim 21, wherein the monomeric insulin analogue has oneor more mutations that reduce or eliminate fibril formation.
 24. Thepharmaceutical composition of claim 23, wherein said one or moremutations comprise a mutation at B24, B25, or B26.
 25. Thepharmaceutical composition of claim 24, wherein the monomeric insulinanalogue contains a halogenated phenylalanine at a positioncorresponding to B24, B25, or B26 of native human insulin, wherein thehalogenated phenylalanine is optionally 2-fluoro, 4-chloro, 2-chloro, or2-bromo.
 26. The pharmaceutical composition of claim 25, wherein themonomeric insulin has 2-fluorophenylalanine at position B24.
 27. Thepharmaceutical composition of claim 24, wherein the amino acid atposition B24 of the monomeric insulin has a non-planar aliphatic ring asa side chain, and wherein the amino acid at position B24 is optionallycyclohexanylalanine (Cha).
 28. The pharmaceutical composition of claim23, wherein the monomeric insulin analogue comprises one or moremutations at positions corresponding to the following positions ofnative human insulin: B2, B3, B4, B10, B13, B17, B28, B29, A8, A10, A12,A13, A14, A17, and A21, and is optionally a single chain insulin. 29.The pharmaceutical composition of claim 28, wherein the monomericinsulin analogue has a lysine at the position corresponding to Pro^(B28)and a proline at the amino acid corresponding to Lys^(B29).
 30. Thepharmaceutical composition of claim 28, wherein the monomeric insulinanalogue has an aspartic acid at the position corresponding toPro^(B28).
 31. The pharmaceutical composition of claim 28, wherein themonomeric insulin analogue has a lysine at the position corresponding toAsn^(B3), and glutamic acid at the position corresponding to Lys^(B29).32. The pharmaceutical composition of claim 28, wherein the monomericinsulin analogue contains one or more of: Leu at the positioncorresponding to A3; Glu, His, Gln at the position corresponding to A8;Cys at the position corresponding to A10; Asp or Thr at the positioncorresponding to A12; Trp, Tyr, His, Glu, Ala, or Phe at the positioncorresponding to A13; His or Glu at the position corresponding to A14;Trp, Tyr, Ala, His, Glu, Gln, Phe, or Apn, at the position correspondingto A17 Gly at the position corresponding to A21; Cys at the positioncorresponding to B2; Lys at the position corresponding to B3; Cys at theposition corresponding to B4; Asp at the position corresponding to B10;Trp, Tyr, Ala, His, Glu, Phe, Apn, or Gln at the position correspondingto B13; Trp, Tyr, His, or Gln at the position corresponding to B17; Trp,Tyr, His, Gln, Asp, Thr, Ala, Phe, or Cha at the position correspondingto B24; and Glu at the position corresponding to B29.
 33. ThePharmaceutical composition of claim 21, wherein the monomeric insulinanalogue has a deletion of amino acids B1-B3.
 34. The pharmaceuticalcomposition of claim 33, wherein the monomeric insulin analogue has anornithine or Glu at position B29.
 35. The pharmaceutical composition ofclaim 21, wherein the monomeric insulin analogue has a B chain with theamino acid sequence KPIEE, EPIEE, POTEE, or POTO at the C-terminalsegment respectively comprising residues B28-B32, B28-32, B28-B32, andB28-B31, in which residues B31-B32 C-terminal extensions of the B chain.36. The pharmaceutical composition of any one of claims 1 to 35, whereinthe monomeric insulin analogue is a single chain insulin having apeptide linker between the A and B chains.
 37. The pharmaceuticalcomposition of claim 36, wherein the peptide linker is between 4 and 10amino acids, optionally comprising the sequence GPRR.
 38. Thepharmaceutical composition of claim 37, wherein the peptide linker hasthe sequence: GGGPRR, GGPRR, GSEQRR, RREQKR, RREALQKR, GAGPRR, orGGGPGKR, EEGSRRSR, EEGPRR, GEGPRR, AEGSRRSR, ASGSRRSR, EEGSRRD, orEEGSRRK.
 39. The pharmaceutical composition of any one of claims 1 to38, wherein the composition comprises one or more pharmaceuticallyacceptable excipients.
 40. The pharmaceutical composition of claim 39,wherein the composition comprises one or more of a pharmaceuticallyacceptable buffer, stabilizing agent(s), surfactant(s), solubilizingagent, anti-aggregation agent, diffusion-enhancing agent, absorptionenhancing agent, and preservative(s).
 41. The pharmaceutical compositionof claim 39, wherein the composition comprises one or moreanti-inflammatory agents and/or one or more anti-fibrotic agents. 42.The pharmaceutical composition of claim 39, wherein the compositioncomprises a peptide agent that opens tight junctions.
 43. Thepharmaceutical composition of any one of claims 1 to 42, wherein thecomposition is provided within an insulin infusion set.
 44. An infusionset comprising a first body, an adhesive surface, a subcutaneousinfusion catheter, and one or more of an ultrasound transducer, atactor, and an electrophoresis electrode.
 45. The infusion set of claim44, wherein the transducer, tactor, and/or electrophoresis electrodeincreases the rate at which a pharmaceutical formulation is absorbedinto the circulation from a subcutaneous depot.
 46. The infusion set ofclaim 45, wherein the pharmaceutical formulation is an insulinformulation, and which is optionally a rapid-acting insulin formulation.47. The infusion set of claim 46, wherein the insulin formulation is asubstantially zinc-free formulation of a stable monomeric insulinanalogue or dimeric insulin analogue.
 48. The infusion set of claim 46,wherein the formulation is a pharmaceutical composition of any one ofclaims 1 to
 43. 49. The infusion set of claim 48, wherein the infusioncatheter projects about 1 mm to about 10 mm into the subcutis, andoptionally about 7 mm into the subcutis.
 50. The infusion set of claim49, further comprising a supply tube or port to which a supply tube canbe connected, where a pharmaceutical composition reservoir can beconnected and disconnected to the supply tube.
 51. The infusion set ofclaim 50, further comprising a pump and controller operably connected tothe reservoir delivering a pharmaceutical composition through the supplytube to the catheter.
 52. The infusion set of claim 51, wherein thecontroller comprises a microprocessor, a control algorithm, and aninterface display, which are optionally contained in the first body. 53.The infusion set of claim 52, further comprising one or more externaluser controls and/or a communication interface, which are optionallycontained in the first body.
 54. The infusion set of claim 51, whereinthe reservoir is comprised in a second body that can be detached fromthe first body.
 55. The infusion set of claim 54, wherein the adhesivesurface is on the second body, and the second body comprises theinfusion catheter.
 56. The infusion set of any one of claims 44 to 55,comprising a low intensity ultrasound (LITUS) transducer orlow-frequency piezoelectric tactor.
 57. The infusion set of claim 56,wherein the LITUS transducer or tactor is contained within the firstbody, and is optionally positioned above the distal end of the infusioncatheter.
 58. The infusion set of claim 56, wherein the ultrasoundtransducer or tactor is powered by a battery that powers a pump, and isoptionally driven by a signal generator in the pump.
 59. The infusionset of claim 56, wherein the ultrasound transducer emits a signal withinthe range of about 0.2 MHz to about 3 MHz, and optionally in the rangeof about 0.5 MHz to 2.5 MHz, and optionally in the range of about 1 to 2MHz, and optionally about 1.0, 1.5, or 2.0 MHz.
 60. The infusion set ofclaim 56, wherein the piezoelectric tactor has a frequency of less thanabout 1 kHz.
 61. The insulin infusion set of claim 56, wherein thesignal is continuous or pulsed.
 62. The infusion set of claim 59,wherein the adhesive surface is ultrasonically transmissive.
 63. Theinfusion set of any one of claims 44 to 55, comprising a firstelectrophoresis electrode proximal to the distal end of the infusioncatheter.
 64. The infusion set of claim 63, wherein the adhesive surfaceis electrically conductive.
 65. The infusion set of claim 63, furthercomprising a second electrophoresis electrode on the skin surface, whichis optionally attached to the adhesive surface.
 66. The infusion set ofclaim 65, wherein the second electrode has a coating increasingelectrical conductivity to the skin, and which is optionally anelectrochemical gel or adhesive.
 67. The infusion set of claim 65,wherein the second electrode is positioned above the distal end of theinfusion catheter.
 68. The infusion set of claim 65, wherein the firstand second electrophoresis electrodes are connected to opposite ends ofa voltage source.
 69. The infusion set of claim 68, wherein the voltageis a constant voltage, and the voltage is optionally in the range of 1volt to about 15 volts, and is optionally in the range of 1 volt toabout 10 volts.
 70. The infusion set of claim 68, wherein the firstelectrophoresis electrode is the cathode and the second electrophoresiselectrode is the anode.
 71. The infusion set of claim 70, wherein theelectrodes are connected by an electrical conductor to an interfaceplug, wherein the plug can be connected and disconnected to the voltagesource.
 72. The infusion set of claim 70, wherein the electrophoresiselectrodes comprise a conductive coating.
 73. The infusion set of claim72, wherein the conductive coating comprises a material withanti-microbial characteristics.
 74. The infusion set of claim 73,wherein the anti-microbial material comprises a silver-containingcompound.
 75. The infusion set of any one of claims 44 to 74, furthercomprising a reservoir of a pharmaceutical formulation.
 76. An infusionset system, comprising the insulin infusion set of any one of claims 44to 75, and a catheter insertion device.
 77. A method for treating asubject with diabetes mellitus, comprising: administering thepharmaceutical composition of any one of claims 1 to 43 to said subject.78. The method of claim 77, wherein the patient has type 1 diabetes ortype 2 diabetes, and where the patient optionally suffers from obesityor metabolic disease.
 79. The method of claim 77, wherein the patienthas prediabetes.
 80. The method of any one of claims 77 to 79, whereinthe composition is administered less than about 20 minutes before ameal.
 81. The method of any one of claims 77 to 79, wherein thecomposition is administered within 10 to 20 minutes of commencing ameal.
 82. The method of claim 80 or 81, wherein the composition isadministered three times daily in connection with meals.
 83. The methodof any one of claims 77 to 79, wherein the composition is administeredupon symptoms of hyperglycemia.
 84. The method of any one of claims 77to 83, wherein the patient is undergoing a regimen of basal insulinformulation or basal insulin analogue formulation.
 85. The method of anyone of claims 77 to 84, wherein the composition is administered as asingle-bolus subcutaneous injection or infusion.
 86. The method of claim85, wherein the composition is administered by an infusion set of anyone of claims 43 to
 76. 87. The method of claim 86, wherein thecomposition is automatically administered upon a detection of low bloodglucose by the insulin infusion system.
 88. The method of claim 86,wherein the composition is administered in an injectate volume of lessthan about 0.1 ml.
 89. The method of claim 86, wherein one or more oflow intensity ultrasound (LITUS), mechanical massage, andelectrophoresis is initiated at the injection site, to thereby increasethe speed of insulin uptake into the circulation.
 90. The method ofclaim 89, wherein the ultrasound, mechanical massage, and/orelectrophoresis operates for at least 10 minutes before and/or after theinjection.
 91. The method of claim 89, wherein the ultrasound,mechanical massage, and/or electrophoresis operates for at least 30minutes before and/or after the injection, or at least one hour beforeand/or after the injection.
 92. The method of claim 86, wherein theultrasound, mechanical massage, and/or electrophoresis is turned offmanually by the subject, or operates for a predetermined amount of time,or operates for an amount of time determined by an algorithm.
 93. Themethod of claim 87, wherein the patient receives the composition ascontrolled by an artificial pancreas system.
 94. A method for treating asubject with diabetes, comprising: administering a rapid acting insulinformulation to said subject, using the insulin infusion set of any oneof claims 44 to
 76. 95. The method of claim 94, wherein the patient hastype 1 diabetes mellitus or type 2 diabetes mellitus, and where thepatient optionally suffers from obesity or metabolic disease.
 96. Themethod of claim 94, wherein the patient has prediabetes.
 97. The methodof any one of claims 94 to 96, wherein the rapid acting insulin isadministered less than about 20 minutes before a meal.
 98. The method ofany one of claims 94 to 96, wherein the rapid acting insulin compositionis administered within 10 to 20 minutes of commencing a meal.
 99. Themethod of claims 97 to 98, wherein the rapid-acting insulin compositionor rapid-acting insulin analogue composition is administered three timesdaily in connection with meals.
 100. The method of any one of claims 94to 96, wherein the rapid-acting insulin composition or rapid-actinginsulin analogue composition is administered upon symptoms ofhyperglycemia.
 101. The method of any one of claims 94 to 100, whereinthe patient is undergoing a regimen of basal insulin formulation orbasal insulin analogue formulation.
 102. The method of claim 101,wherein the basal insulin formulation or basal insulin analogueformulation is administered from one to three times daily, or isadministered by continuous infusion.
 103. The method of any one ofclaims 94 to 102, wherein the rapid-acting insulin composition orrapid-acting insulin analogue formulation is administered as a singlebolus subcutaneous injection.
 104. The method of claim 102, wherein therapid-acting insulin formulation or rapid-acting insulin analogueformulation is automatically administered upon a detection of low bloodglucose by the insulin infusion system.
 105. The method of any one ofclaims 94 to 104, wherein ultrasound, mechanical massage, and/orelectrophoresis operates for at least about 10 minutes before and/orafter injection of the rapid-acting insulin formulation or rapid-actinginsulin analogue formulation.
 106. The method of claim 105, whereinultrasound, mechanical massage, and/or electrophoresis operates for atleast about 30 minutes before and/or after injection of the rapid-actinginsulin formulation or rapid-acting insulin analogue formulation, or atleast one hour before and/or after the injection of the rapid actinginsulin or analogue.
 107. The method of claim 105 or 106, wherein theultrasound, mechanical massage, and/or electrophoresis is turned offmanually by the subject, or operates for a predetermined amount of time,or operates for an amount of time determined by an algorithm.
 109. Themethod of any one of claims 94 to 107, wherein the patient receives therapid acting insulin composition and a basal insulin composition, ascontrolled by an artificial pancreas system.